Central venous saturation as a predictor of extubation failure*
T olerance of a spontaneous
breathing test (SBT) indicates
weaning success, but variably
predicts extubation success.
After successful SBT, the need for reintu-
bation within the subsequent 24 hrs to 72
hrs occurs in 5% to 30% of patients,
depending on the population (1). The dif-
ficult-to-wean patient, by definition, has
failed to tolerate the initial SBT with suc-
cessful weaning requiring up to three
SBTs or up to no more than 7 days from
the initial SBT evaluation. After a suc-
cessful SBT in this population, 15% to
33% will fail the extubation trial and re-
quire reintubation (2). Thus, identifying a
noninvasive measure during the SBT,
which could accurately predict extuba-
tion outcome for these difficult-to-wean
patients, would inform the clinical deci-
sion to extubate.
In this issue of Critical Care Medicine,
Teixeira et al (3) evaluate the change in
central venous saturation (ScvO2) during
the SBT as a predictor of extubation failure
in difficult-to-wean patients. The authors
hypothesized that ScvO2 could be a “reliable
and convenient tool to rapidly warn about
the acute changes in oxygen supply and
demand of the patient during weaning.”
Across three medical-surgical inten-
sive care units, 73 patients mechanically
ventilated for ⬎48 hrs who had previ-
ously failed a 2-hr SBT were enrolled in
the study. All patients were weaned, using
a standardized two-step process which in-
cluded daily readiness to wean assess-
ments, a 2-hr T-piece SBT with measure
of frequency/tidal volume (f/VT) ratio dur-
ing the first 30-min interval, and mea-
sures of various physiologic and ventila-
tory parameters at 1 min and the 30 mins
of the SBT. All patients had a subclavian
or internal jugular central venous catheter
*See also p. 491.
Key Words: extubation failure; difficult-to-wean;
spontaneous breathing trial; mechanical ventilation;
central venous saturation; predictor
The author has not disclosed any potential con-
flicts of interest.
Copyright © 2010 by the Society of Critical Care
Medicine and Lippincott Williams & Wilkins
DOI: 10.1097/CCM.0b013e3181c585fb
708
present for ScvO2 measurement. Patients
with an f/VT ⬎105 or intolerance of the
SBT were returned to ventilatory support
and reassessed the next day (4, 5). Patients
who had an f/VT ⱕ105 and who successfully
passed an SBT were extubated and moni-
tored for 48 hrs. The protocol among all
three institutions included immediate use
of noninvasive ventilation on extubation for
all patients with chronic obstructive pul-
monary disease. Extubation failure (EF)
was defined as the need for reintubation
within 48 hrs of extubation.
EF occurred in 31 patients (42.5%).
Significant differences between the EF
and extubation success (ES) group were
detected at the 30th minute of the SBT
including an increased heart rate, lower
PaO2, SaO2, and ScvO2 in the EF group.
Multivariate regression identified ScvO2
as the only independent variable able to
discriminate extubation outcome. At 30
mins of the SBT, the ScvO2 in the EF
group was 60 ⫾ 8 as compared with 70 ⫾
7 in ES group (p ⫽ .009). A reduction in
ScvO2 by ⬎4.5% during the SBT was an
independent predictor of reintubation,
with an odds ratio of 49.5 (95% confi-
dence interval, 12.1–201.5), sensitivity of
88% and specificity of 95%. These results
indicate that ScvO2 measured during a
T-piece trial may be an important part of
the assessment of extubation readiness in
the difficult-to-wean patient.
The utility of ScvO2 as a surrogate for
Sv៮ O2 in clinical-decision making has been
evaluated with conflicting results, partic-
ularly in the critically ill patient (6 –9).
The ScvO2 has performed well as a surro-
gate target for hemodynamic resuscita-
tion, yet it seems to have a variable cor-
relation with the Sv៮ O2, depending on the
patient’s disease and severity of cardio-
pulmonary status at the time of measure-
ment. In 60 patients with low cardiac
index, the limits of agreement between
the Sv៮ O2 and ScvO2 were ⫺19% to ⫹18%
with a correlation coefficient of 0.46 to
0.72 (7). The correlation between these
two measures has been evaluated among
various populations of intensive care pa-
tients, resulting in estimates between
0.78 and 0.95 (6 –9). Chawla et al found
that ScvO2 overestimated the true Sv៮ O2 by
⫾5% and that large estimation errors
occurred in calculating oxygen consump-
tion (V̇O2) from substitution of the ScvO2
values (8).
Using Sv៮ O2 to predict weaning success
and failure has been well described. Jub-
ran et al reported the continuous mea-
sure of Sv៮ O2 during the SBT could accu-
rately discriminate among a cohort of 8
patients who had failed the SBT and 11
patients who passed the SBT (9). SvO2 fell
persistently during the SBT in the failure
group leading to systemic arterial desatu-
ration. The EF group did not alter their
oxygen consumption nor cardiac index,
rather the oxygen extraction ratio was
increased. Jubran et al concluded that the
progressive decrease in Sv៮ O2 during a
failed SBT was due to a combination of
decreased oxygen transport and increased
oxygen extraction by the tissues. In the
current study by Dr. Teixeira et al, a de-
crease in ScvO2 measured during the SBT
was able to predict accurately extubation
outcome. Other independent predictors
of extubation outcome in difficult-to-
wean patients include n-terminal pro-
brain natriuretic peptide, measures of
work of breathing, such as maximal in-
spiratory pressure, peak cough expiratory
force, and secretion burden (10 –13).
Importantly, the study cohort evalu-
ated difficult-to-wean patients. All pa-
tients had previously passed both an f/VT
and SBT trial, which should indicate a
high likelihood of ES. However, it is
known that a high likelihood of EF oc-
curs in the difficult-to-wean population
and, therefore, the use of the ScvO2 as a
predictor of extubation outcome may not
be easily generalizable to other patient
populations who may have a much higher
probability for ES. The reader is, there-
fore, cautioned against using a decreased
ScvO2 during the SBT as evidence to
withhold a trial of extubation in the gen-
eral patient population either passing
their first SBT or otherwise having met
extubation readiness criteria. The impor-
tance of appropriate application and in-
terpretation of weaning-predictor tests
has been previously described (14).
Although this study has defined how
to identify risk for failed extubation, it is
Crit Care Med 2010 Vol. 38, No. 2
not able to further define the potential
etiology of EF in these patients nor does
the study propose potentially successful
interventions. In a recent cohort study of
difficult-to-wean patients with decreased
left ventricle EF (⬍40%) the use of levo-
simendan was associated with improved
weaning success and ES (15). Whether
these results are applicable to this popu-
lation with chronic obstructive pulmo-
nary disease and sepsis is not known. It
would be interesting to study these diffi-
cult-to-wean patients to determine
whether the decrease in ScvO2 is a marker
of “stress” during the SBT, and, there-
fore, whether a trial of noninvasive ven-
tilation or pharmacologic intervention
may facilitate ES as this has been dem-
onstrated to be successful in preventing
EF when applied selectively in other
high-risk groups (15, 16).
Angela T. Wratney, MD, MHSc,
FAAP
Critical Care Medicine
Children’s National Medical
Center
The George Washington
University
Washington, DC
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The authors have not disclosed any potential con-
flicts of interest.
Copyright © 2010 by the Society of Critical Care
Medicine and Lippincott Williams & Wilkins
DOI: 10.1097/CCM.0b013e3181bfeaf7
Crit Care Med 2010 Vol. 38, No. 2
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assumed to have equal efficacy. These au-
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