Measurement of skeletal muscle tissue oxygenation in the critically ill

Shock is a state of acutely reduced tissue oxygenation. In cardiogenic shock oxygen delivery (DO2) is reduced, but oxygen extraction is preserved. In septic shock DO2 is preserved, but oxygen extraction is decreased because of microvascular changes and disturbed metabolism. Global assessment of DO2 and oxygen consumption does not tell us enough about adequacy of regional perfusion. The aim of this study was to assess the value of near infrared spectroscopy (NIRS) in detecting skeletal muscle tissue oxygenation (StO2) in critically ill patients. 

Patients in cardiogenic shock (n=17), septic shock (n=14), without shock but with localized infection (n=14) and healthy volunteers (n=15) were included. Thenar StO2 was measured with NIRS before (baseline StO2, %), between (downward StO2 slope, %/min) and after 90 seconds of upper arm stagnant ischemia (hyperemic StO2, %). Muscle oxygen extraction (mOER) was calculated as follows: mOER (%) = (1-baselineStO2/hyperemic StO2)*100. Repeatability was assessed using the Bland Altman method (95 % of values within limits of agreement), comparing 55 pairs of measurements performed in 5-minute intervals.

Repeatability of measurements was clinically acceptable. Compared to septic shock patients, cardiogenic shock patients had lower baseline StO2 (68.9 ± 10.0 % vs. 84.3 ± 10.4 %; p < 0.05) and hyperemic StO2 (80.8 ± 7.8 % vs. 91.8 ± 8.3 %; p < 0.05), and a higher downward StO2 slope (-17.4 ± 31.7 %/min vs. -9.1 ± 2.6 %/min; p < 0.05). mOER was higher in healthy volunteers (11.9 ± 3.8 %) and volunteers with cardiogenic shock (14.8 ± 7.3 %) compared to septic shock patients (8.1 ± 7.8 %) and those with localized infection (7.6 ± 5.4 %) (p < 0.05).

Repeatability of baseline StO2 and hyperemic StO2 is clinically acceptable. Results support the hypothesis that skeletal muscle oxygen extraction capability is preserved and extraction is increased in cardiogenic shock compared to septic shock.

repeatability, NIRS, tissue oxygenation, cardiogenic shock

1. Hameed SM, Aird WC, Cohn SM. Oxygen delivery. Crit Care Med 2003;31(12 Suppl):S658-67.

2. Lim N, Dubois MJ, De Backer D, Vincent JL. Do all nonsurvivors of cardiogenic shock die with low cardiac index. Chest 2003;124:1885-91.

3. Ince C, Sinaasappel M. Microcirculatory oxygenation and shunting in sepsis and shock. Crit Care Med 1999;27:1369-77.

4. Fink MP. Cytopathic hypoxia: Is oxygen use impaired in sepsis as a result of an acquired intrinsic derangement in cellular respiration?Critical Care Clin 2002;18:165-75.

5. Creteur J, De Backer D, Vincent JL. A dobutamine test can disclose hepatospalnchnic hypoperfusion in septic patients. Am J Resp Crit Care Med 2002;160:839-45.

6. Lima A, Bakker J. Noninvasive monitoring of peripheral perfusion. Intensive Care Med 2005;31:1316-26.

7. Abou-Khalil B, Scalea TM, Trooskin SZ, Henry SM, Hitchcock R. Hemodynamic responses to shock in young trauma patients: need for invasive monitoring. Crit Care Med 1994;22:633-9.

8. Scalea TM, Maltz S, Yelon J, Trooskin SZ, Duncan AO, Sclafani SJ. Resuscitation of multiple trauma and head injury: role of crystalloid fluids and inotropes. Crit Care Med 1994;22:1610-5.

9. Ivatury RR, Simon RJ, Islam S, Fueg A, Rohman M, Stahl WM. A prospective randomized study of end points of resuscitation after major trauma: global oxygen transport indices versus organ-specific gastric mucosal pH. J Am Coll Surg 1996;183:145-54.

10. Sessler DI. Skin-temperature gradients are a validated measure of fingertip perfusion. Eur J Appl Physiol 2003;89:401-2.

11. Boushel R, Piantadosi CA. Near-infrared spectroscopy for monitoring muscle oxygenation. Acta Physiol Scand 2000;168:615-22.

12. Wahr JA, Tremper KK, Samra S, Delpy DT. Near-infrared spectroscopy: theory and applications. J Cardiothorac Vasc Anesth 1996;10:406-18.

13. Shepherd JT. Circulation to skeletal muscle. In: Abboud FM, Shepherd JT, editors. Handbook of physiology. Vol. 3. Bethesda (USA); 1983. p. 319-70.

14. Malmstrom BG, Aasa R. The nature of the CuA center in cytochrome c oxidase. FEBS Lett 1993;325:49-52.

15. De Blasi R, Quaglia E, Gasparetto A, Ferrari M.Muscle oxygenation by fast near infrared spectrophotometry (NIRS) in ischemic foreram. Adv Exp Med Biol 1992;316:163-72.

16. Colier WN, Meeuwsen IB, Degens H, Oeseburg B. Determination of oxygen consumption in muscle during exercise using near infrared spectroscopy. Acta Anaesthesiol Scand 1995;39(Suppl 107):151-55.

17. Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, et al. Definitions for sepsis and organ failure and guidelines for the use of inovative therapies in sepsis. Chest 1992;101:1644-55.

18. Sair M, Etherington PJ, Winlove P, Ewans TW. Tissue oxygenation and perfusion in patients with systemic sepsis. Crit Care Med 2001;29:1343-49.

19. Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Intensive Care Med 2004;30:536-55.

20. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurements. Lancet 1986:307-10.

21. Shoemaker WC. Circulatory mechanisms of shock and their mediators. Crit Care Med 1987;15:787-94.

22. De Backer D, Creteur J, Dubois MJ, Sakr Y, Vincent JL. Microvascular alterations in patients with acute severe heart failure and cardiogenic shock. Am Heart J 2004;147:91-9.

23. Simonson SG, Welty-Wolf K, Huang YT, Griebel JA, Caplan MS, Fracica PJ, et al. Altered mitochondrial redox responses in gram negative septic shock in primates. Circ Shock 1994;43:34-43.

24. Duhaylongsod FG, Griebel JA, Bacon DS, Wolfe WG, Piantadosi CA. Effects of muscle contraction on cytochorme a, a3 redox state. J Appl Physiol 1993;75:790-7.

25. Girardis M, Rinaldi L, Busani S, Flore I, Mauro S, Pasetto A. Muscle perfusion and oxygen consumption by near-infrared spectroscopy in septic shock and non-septic patients. Intensive Care Med 2003;29:1173-6.

26. Singer M, Brealey D. Mitochondrial dysfunction in sepsis. Biochem Soc Symp 1999;66:149-66.

27. Singer M, DeSantis V, Vitale D, Jeffcoate W. Multiorgane failure is an adaptive, endocrine-mediated, metabolic response to overwhelming systemic inflammation. Lancet 2004;364:545-7.

28. Tran TK, Sailasuta N, Kreutzer U, Hurd R, Chung Y, Mole P, et al. Comparateive analysis of NMR and NIRS measurements of intracellular PO2 in human skeletal muscle. Am J Physiol 1999;276:R1682-90.

29. Mancini DM, Wilson JR, Bolinger L, Li H, Kendrick K, Chance B, et al. In vivo magnetic resonance spectroscopy measurement of deoxymyglobin during exercise in patients with heart failure. Demonstration of abnormal muscle metabolism despite adequate osygenation. Circulation 1994;90(1):500-8.