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6 Key steps inOoxygen cascade
2
ATP - Energy
2
OXYGENATION
3
Oxygenation
UDARA BEBAS:
PiO2 : 21% x 760 = 160 mmHg
PiCO2 : 0.04 % x 760 = 0.3 mmHg
ALVEOLUS
PiN2 : 78.6 % x 760 = 597mmHg
PiH2O : 0.46 % x 760 = 3.5 mmHg
N2 H 2O
KAPILER PARU
PAN2: PAH2O:
PROSES DIFUSI 573 mmHg 47 mmHg
4
Normal partial pressure relationships
5
PiO2 = 760 x .21
= 160
150
A-a O2 gradient
104 – 100 = 4
100
a-v O2 gradient
PO2 100 – 40 = 60
50
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Oksigen ditranspor ke jaringan dalam 2
bentuk
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Larut dalam plasma
Jumlah oksigen yg larut dalam plasma sangat
kecil
– Pada suhu 370C dan tekanan 760 mmHg, 1 ml darah
hanya dapat mengangkut oksigen sebesar 0.023 ml.
– 0.023/760 = 0.003 ml oksigen yg terlarut dalam 100 ml
darah Text
Text
Text
– Jika PaO2 100, berarti jumlah
Text yg terlarut dalam
plasma;
8
Berikatan dengan hemoglobin
9
Oxygen Content dalam darah
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CaO2
11
UDARA BEBAS:
PiO2 : 21% x 760 = 160 mmHg
PiCO2 : 0.04 % x 760 = 0.3 mmHg
ALVEOLUS
PiN2 : 78.6 % x 760 = 597mmHg
PiH2O : 0.46 % x 760 = 3.5 mmHg
N2 H 2O
KAPILER PARU
PAN2: PAH2O:
PROSES DIFUSI 573 mmHg 47 mmHg
12
CcO2
= (1.34 x Hgb x 1.0) + (PAO2 x 0.0031)
The saturation of oxygen in the pulmonary end-capillary should
be 1.0 if FiO2 > 0.21
PAO2 = alveolar oxygen tension
= FiO2 x [(PB-PH20)-(PaCO2/RQ)]
PB = barometric pressure, PH2O = water vapor
pressure, RQ = respiratory quotient
= 0.40 x [(760 mmHg - 47 mmHg) - (40
mmHg/0.8) = 0.40 x 663 mmHg
= 265 mmHg
PAO2 can also be approximated rapidly at the bedside as 700 torr x FiO2 - 50 torr
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CvO2
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Ca-vO2
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Oxygen Dissociation Curve
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Oxygen Dissociation Curve
100
100, 97%
60, 90%
75
40, 75%
O2 Sat
(%) 50
27, 50%
25
10 20 30 40 50 60 70 80 90 100
PO2
17 (mm Hg)
100
80
flat portion of curve:
O2 Sat 60 large changes of PO2 result in
very small changes in oxygen
(%) saturation or content.
40
20
10 20 30 40 50 60 70 80 90 100
PO2 (mm
18
Hg)
100
80
steep portion of curve:
O2 Sat small changes of PO2 result in
60 large changes in oxygen
(%) saturation or content.
Results in enhanced oxygen release.
40
20
10 20 30 40 50 60 70 80 90 100
PO2 (mm
19
Hg)
Significance of Sigmoid Curve
Critical PO2
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Four Things Change Oxyhemoglobin Affinity
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Hydrogen Ion
Inhibited
Unloading
Better
Unloading
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Carbon Dioxide
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Temperature
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2,3-DPG
2,3-DPG merupakan glycolytic
intermediate
– Konsentrasi paling banyak di eritrosit
– ↑ 2,3-DPG ↑ P50
– ↓ 2,3-DPG ↓ P50
↑ 2,3-DPG berhubungan dgn hipoksia
25
Kondisi-kondisi yg meningkatkan konsentrasi
2,3-DPG
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Blood Bank Storage
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DPG and O2 Carrying
12,0
Fresh Blood
6,0
3,0
0,0
0 5 10 15Hamasaki et al. Vox
20 Sang 2000; 79:191-197.
25
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OXYGEN DELIVERY
Cardiac Output x CaO2 =
CO x [Hb] x 1.34 x % sat + PaO2 x 0.003 ml
O2/ dl / mm Hg
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Oxygen delivery/transport
Uptake in the Lung Oxygenation PaO2
CaO2
CaO2 = Cardiac
DO2 = Arterial Oxygen Content
x
Output
SaO2 x 1.34 x Hb
SV x HR
31
VO2I
= index dari oxygen consumption
= volume dari O2 yg dikonsumsi oleh tubuh
per minute per meter persegi (BSA)
= volume dari oksigen yg meninggalkan
jantung - volume oksigen yg kembali ke
jantung
= [(CI x CaO2) - (CI x CvO2)] x 10dL/L
= CI x Ca-vO2 x 10 dL/L
= ~150 ml O2/min.m-2
32
O2ER
Keseimbangan antara suplay dan pemakaian
oksigen di jaringan dapat dilihat pada 2
parameter oksigenasi, yaitu:
– Oxygen utilization coefficient (OUC) and
– Mixed venous oxygen saturation (SvO2).
OUC, juga dapat disebut sebagai oxygen
extraction ratio atau O2ER, yg merupakan
persentasi oksigen delivery yg terpakai oleh
tubuh, yg dihitung sbb:
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O2ER
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MIXED VENOUS OXYGEN SATURATION
(SvO2)
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Mixed Venous Oxygen
Saturation (SvO2):
What is it?
What is it Good For?
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SvO2: What is it?
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SvO2: Definition by Formula
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Derivation…
Fick equation:
VO2 = CO (CaO2 - CvO2 )
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Derivation (continued)
So, substituting into the equation:
VO2 = CO (CaO2 - CvO2 )
VO2 = CO ([1.38 x Hgb x SaO2] - [1.38 x Hgb x SvO2])
40
…but we don’t usually
calculate the SvO2 - we
usually measure it.
41
How Do We Measure It?
Oximetric Swan
– Two wavelength systems
– Three wavelength systems
Direct measurement
– Blood sample from distal lumen of pulmonary artery
catheter can be analyzed by a normal blood gas
machine
– Does not show trends
– Used for calibration
42
What is the Normal Value?
The normal value of SvO2 is 68% to
77%
43
What does it tell us?
Gives information about the adequacy of oxygen delivery
Suggests information about oxygen consumption at the
cellular level
A measure of physiologic compensatory mechanisms (i.e.
increase in CO)
Can help determine usefulness of clinical intervention
(what is the “best” PEEP, change in drip, etc.)
Might be useful when other monitors are not available (?)
44
So, how do I use it?
45
Decreases in SvO2
If SvO2 decreases, it means that oxygen delivery
is not high enough to meet tissue needs
This might be due to inadequate oxygen delivery
(poor saturation, anemia, insufficient cardiac
output)
Or, it might be due to increased tissue extraction
(fever, shivering, thyrotoxicosis, agitation,
exercise, etc.)
46
Increases in SvO2
47
Acute ↓ DO2
In Shock or
•Anemia
Catabolic State
•Hypoxemia
•CO↓
O2ER ↑
Cellular Hypoxia
O2O2ER
ER ↑==25%
50% VO2 ñ
SvO2
DO2 ↓ 50%
Cellular/Mitochondrial
O2ER = 10%
dysfunction
SvO2
DO2 n/↑ 90%
Normal relationship
Pathologic condition
VO2 ↑ ; catabolic state, sepsis, increased
muscle activity, awakening, hyperthermia,
shivering, inotrope excess, etc.
300
VO2 tidak tergantung DO2
200
Oxygen
Setiap penurunan a VO
DO ; ↓Hb,
2↓ ; rest,
↓ sedation,
SaO ataucontrol
↓
uptake
x i 2 2
(VO2) 100 o akan mempengaruhi
CO,stidak ventilation, hypothermia
uptake O2 dari
y
Dsel, hal ini disebabkan sel-sel mempunyai
= kemampuan
c k D O 2 meningkatkan ekstraksi O2
h o tu n g
Critical
S rg a n ↓ Critical DO 2
DO
te 2
2
VO ↑ Critical DO2
Microcirculation
Organ distribution Autoregulation
Diffusion Distance
ATP - Energy
51
DIAGNOSING THE SHOCK TYPE
↓CaO2 = ↓Cardiac
↓DO2 = Hypoxemia, Hemorrhagic x Output
Arterial Oxygen Content
poisoning shock
1. Quantitative Shock
↓volume Afterload ↓Contract
1. Decreased CaO2
2. Decreased Flow Mitochondria problem
Hypovolemic Cardiogenic
2. Distributive Shock shock shock
Cytopathic
hipoxia
MMDS
↓O2ER ↓Capillary Flow
recruitment redistribution
Microcirculation problem
52
Goal-directed Therapy
Microcirculation
Arteries PaO2
Capillaries PcO2
H O
H22O
Kuper, 2004. The Oxygen Whirlpool, in: Year Book of Emergency and
Critical Care Medicine
55
Shifting the Paradigm
Listen to what the cells say…
56
Interpretation of
hemodynamic data Low
SvO2
starting from SvO2
Low Normal
SaO2 SaO2
Hypoxemia ↑ O2ER
CO ↑ CO ↓
VO2↑ VO2 n
PAW ↓ Hypovolemia
Heart Failure
Exercise PAW ↑
Stress Anemia
Anxiety
PAP ↑ Obstruction
58
Clinical Example #2
Hemmorhage during bowel surgery
No cardiac risk factors
Traditional measures (HR, SpO2, BP, CO,
Hgb) do not tell us how oxygen deprived the
tissues are
59
Clinical Example #3
Patient in cardiogenic shock
Cardiac output is down and less oxygen is being
delivered
Use SvO2 to help assess the adequacy of
interventions to increase cardiac output
60
Clinical Example #4
Patient is a vascular cripple undergoing major
vascular surgery
Unable to get a blood pressure cuff reading
Unable to get an arterial line
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Jugular Venous Oxygen Saturation
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