OXYGEN TRANSPORT

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 6 Key steps inOoxygen cascade
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Uptake in the Lung Oxygenation PaO2

Carrying capacity Haemoglobin SaO2 - Ht DO2

Delivery Cardiac Output Flow rate - ø

Organ distribution Autoregulation

Nervous Syst
Humoral
Diffusion Distance Diffusion distance
Local Control

Cellular use Mitochondria

ATP - Energy
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OXYGENATION

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 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

PAO2: PACO2: Pulmonary Vein

104 mmHg 40 mmHg PaO2
Pulmonary Artery O2 O2 CO2 O2
PvO2:
40 mmHg CO2 CO2
PcCO2: 45 PcCO2: 40
mmHg PcO2: 100 mmHg ∴ PAO2 ≈ PcO2
mmHg

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Normal partial pressure relationships

Udara yg masuk ke alveoli akan terdilusi

oleh:
– Uap air - PH2O = 47 mmHg
– CO2- normal = 40 mmHg

Alveolar air equation:

– PAO2 = FIO2 (PB - 47) - (PaCO2 x 1.25)
– PAO2 = 0.21(713) - (40 x 1.25) = 100

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 PiO2 = 760 x .21
= 160
150
A-a O2 gradient
104 – 100 = 4
100

a-v O2 gradient
PO2 100 – 40 = 60
50

PiO2 PAO2 PpcO2 PaO2 PvO2

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Oksigen ditranspor ke jaringan dalam 2
bentuk

Terlarut dalam plasma

Berikatan dengan hemoglobin

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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;

(100 mmHg) (0.003ml/100ml darah/mmHg)

= 0.3 ml O2/100ml darah

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 Berikatan dengan hemoglobin

Setiap gram hemoglobin dapat mengangkut

1.34 ml oksigen
– (1.34 ml O2/gr Hb/100 ml darah)(gr Hb)(SaO2)
Jika pasien Hb 15, dan saturasi 100%;
– 1.34 ml O2/100 ml darah (15 gr Hb/100 ml
darah)(1.0) = 20.1 ml O2/100 ml darah

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Oxygen Content dalam darah

= Hb bound plus dissolved

CaO2 = [Hb] x 1.34 x % saturation

+
PO2 x 0.003 ml O2/ dl / mm Hg

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 CaO2

= 20.1 ml O2/dl blood + 0.3 ml O2/dl blood

= 20.4 ml O2/dl blood

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 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

PAO2: PACO2: Pulmonary Vein

100 mmHg 40 mmHg PaO2
Pulmonary Artery O2 O2 CO2 PcO2: 100 O2
mmHg
PvO2:
40 mmHg CO2 CO2
PcCO2: 45 PcCO2: 40
mmHg mmHg ∴ PAO2 ≈ PcO2

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 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

= 20.1 ml O2/dl blood + 0.8 ml O2/dl blood (assuming

normal values)
= 20.9 ml O2/dl blood

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 CvO2

= (1.34 x 15 g x 0.75) + (40 mmHg x 0.0031) = 15.1 ml

O2/dl blood + 0.12 ml O2/dl blood
= 15.3 ml O2/dl blood

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 Ca-vO2

= perbedaan arterial-venous oxygen

content
= CaO2 - CvO2
= 20.4 ml O2/dl blood - 15.2 ml O2/dl blood
= 5.2 ml O2/dl blood

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Oxygen Dissociation Curve

Karena pengikatan oksigen jarang menimbulkan

masalah, maka perhatian khusus diarahkan terhadap
pelepasan oksigen oleh Hb di jaringan.
Acidemia, hiperkarbia, dan demam akan menggeser
kurva disosiasi ke kanan sehingga akan memperbaiki/
mempermudah pelepasan oksigen di jaringan

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 Oxygen Dissociation Curve
100
100, 97%
60, 90%
75
40, 75%
O2 Sat
(%) 50
27, 50%

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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

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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

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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

Hydrogen Ion Concentration, [H+]

Carbon Dioxide Partial Pressure, PCO2
Temperature
[2,3-DPG]


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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

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Kondisi-kondisi yg meningkatkan konsentrasi
2,3-DPG

Berada di tempat tinggi.

COPD; emphysema.
anemia.
hyperthyroidism.
right to left shunt.
congenital heart disease.
pulmonary vascular disease.

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 Blood Bank Storage

CPD Storage 2,3-DPG depletion

O.D.C. left-shifted oxygen ( P50)
Oxygen unloading impaired

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 DPG and O2 Carrying

12,0
Fresh Blood

9,0 1-Week-Old Blood

Activated Blood

6,0

3,0

0,0
0 5 10 15Hamasaki et al. Vox
20 Sang 2000; 79:191-197.
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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

Haemoglobin Carrying capacity SaO2 DO2

Delivery Cardiac Output Flow rate / Ht

CaO2 = Cardiac
DO2 = Arterial Oxygen Content
x
Output
SaO2 x 1.34 x Hb
SV x HR

Preload Afterload Contract

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 DO2I
= index dari oxygen delivery
= volume dari O2 yg dipompa dari LV per minute
per meter persegi (BSA)
= CI x CaO2 x 10 dL/L
(10 dL/L adalah faktor koreksi karena CI diukur dalam L/min/
m2 sedangkan CaO2 dalam ml/dl)
= ~ 600 ml O2/min.m-2

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 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

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 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

O2ER = VO2I / DO2I

= ~0.25
= 1- SvO2

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MIXED VENOUS OXYGEN SATURATION
(SvO2)

Nilai normal SvO2 adalah 75%, hal ini berarti dalam

kondisi normal, jaringan mengambil/menggunakan
(ekstraksi) oksigen sebesar 25% dari oksigen yang
ditransport (DO2).
Jika ekstraksi oksigen meningkat, maka saturasi mixed
vena akan terlihat menurun; hal ini menyebabkan CaO2
akan menurun. Tubuh akan mengkompensasi dengan
cara meningkatkan flow/CO

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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?

In simple terms, it is the oxygen

saturation of the blood returning to the
right side of the heart.
This reflects, in a way, the amount of
oxygen “left” after the tissues remove
and utilize what they need

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 SvO2: Definition by Formula

The determinants of SvO2 can be

approximately defined by a modified Fick
equation:

SvO2 = SaO2 - (VO2/[CO x 1.38 x Hgb])

So, it is affected by arterial saturation,

oxygen consumption, cardiac output and
hemoglobin

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 Derivation…
Fick equation:
VO2 = CO (CaO2 - CvO2 )

Remember that arterial oxygen content is:

1.38 x Hgb x SaO2 + (0.003 x PaO2)

Similarly, the venous oxygen content is:

1.38 x Hgb x SvO2 + (0.003 x PvO2)

***We can drop the last argument in each oxygen content

equation because the dissolved oxygen is minimal
compared to the amount bound on hemoglobin.

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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])

Then, solve for SvO2:

VO2 / CO = [1.38 x Hgb x SaO2] - [1.38 x Hgb x SvO2]

1.38 x Hgb x SvO2 = [1.38 x Hgb x SaO2] - VO2 / CO

Hgb x SvO2 = [Hgb x SaO2] - VO2 / [CO x 1.38]

SvO2 = SaO2 - VO2 / [CO x 1.38 x Hgb]

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…but we don’t usually
calculate the SvO2 - we
usually measure it.

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 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

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What is the Normal Value?
The normal value of SvO2 is 68% to
77%

Values less than 50% are worrisome

Values less than 30% suggest anaerobic

metabolism

It is more useful to follow trends (in

response to treatment changes) than to
just look at the number at a given point in
time

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 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 (?)

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 So, how do I use it?

Changes in SvO2 should lead the clinician

to look for the cause of that change
It is important to look at the clinical picture
and combine that information with the data
at hand

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 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.)

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 Increases in SvO2

The most common cause of a very elevated SvO2 is

a wedged catheter

May indicate improvement of previous poor

situation

Increases in SvO2 combined with rising lactate

levels indicate tissues are unable to extract oxygen
– This can be seen in such things as septic shock, cyanide
toxicity, carbon monoxide, methemoglobin
– Might also indicate hypothermia, shunt, inotrope excess,
etc.

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 Acute ↓ DO2
In Shock or
•Anemia
Catabolic State
•Hypoxemia
•CO↓
O2ER ↑

Cellular Hypoxia

O2O2ER
ER ↑==25%
50% VO2 ñ

SvO2
DO2 ↓ 50%

SvO2 ↓ 50% O2 return

↓ 500
• If SvO2 decreases, it means that DO2 is not high enough to meet tissue
needs VO2
1. This might be due to inadequate DO2 (poor saturation, anemia, low
cardiac output)
2. Or, it might be due to increased tissue extraction VO2 (fever,
shivering, thyrotoxicosis, agitation, exercise, etc.)
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 Organ failure and
Septic Shock
O2 is available but
cells are unable to extract oxygen
Dysoxia

Cellular/Mitochondrial
O2ER = 10%
dysfunction

SvO2
DO2 n/↑ 90%

SvO2↑ 90% O2 return

900

• Increases in SvO2 combined with rising lactate levels indicate

tissues are unable to extract oxygen
• This can be seen in such things as septic shock, cyanide toxicity,
carbon monoxide, methemoglobin. Might also indicate
hypothermia, shunt, inotrope excess, etc.49
 O2 uptake (VO2) to O2 supply (DO2) relationship

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

0 ml/mnt 400 600 700 1000 ml/mnt

Oxygen Delivery (DO2)

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 Key steps in oxygen cascade

Uptake in the Lung Oxygenation PaO2

CaO2

Haemoglobin Carrying capacity SaO2 DO2

Delivery Cardiac Output Flow rate

Microcirculation
Organ distribution Autoregulation

Diffusion Distance

Cellular use Mitochondria PicO2 O2ER / VO2

ATP - Energy
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 DIAGNOSING THE SHOCK TYPE

↓CaO2 = ↓Cardiac
↓DO2 = Hypoxemia, Hemorrhagic x Output
Arterial Oxygen Content
poisoning shock

↓SaO2x 1.34 x ↓ Hb ↓SV x HR

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
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Goal-directed Therapy

Microcirculation

Trzeciak, Rivers, Critical Care

2005, 9(suppl 4):S20-S26
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 The Oxygen Whirlpool
PiO2
Atmosphere

Alveolus PAO2 100 mmHg

Arteries PaO2

Capillaries PcO2

Cells PicO2 10-20 mmHg

H O
H22O

Kuper, 2004. The Oxygen Whirlpool, in: Year Book of Emergency and
Critical Care Medicine
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 Shifting the Paradigm



Listen to what the cells say…

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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

Vincent JL, (2002) Cardiac output measurement: Is least invasive always

the best?,Crit Care Med Vol 30, No.10
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 Clinical Example #1
Ventilator dependent patient
Need to increase PEEP to improve
oxygenation
Increasing PEEP results in decreased
cardiac output

What is the optimum level of PEEP for this

patient?

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 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

Can we use SvO2 to determine when to

transfuse this patient?

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 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

SvO2 can help determine when drastic measures

should be employed - i.e. minimize measures that
increase oxygen consumption, consider
pharmacologic paralysis, etc.

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 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

Would you consider using SvO2 in place of blood

pressure monitoring and do the case anyways?

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Jugular Venous Oxygen Saturation

A measurement of the oxygen content of the blood in

the jugular vein (just after circulating through the brain)
reflects the consumption of oxygen by brain tissue
Stress and injury can cause oxygen consumption to go
up (causing jugular venous oxygen saturation to go
down
Normally consuming cells will consume proportionately
more of the oxygen from the blood that supplies them
when the rate of delivery decreases

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63