SYSTEM FOR MEASURING BLOOD OXYGEN LEVELS

Abstract: A system and software are described for calculating, in real-time, the mixed venous partial pressure of oxygen in a patient. The system uses a computer, an arterial pressure line and a blood chemistry monitor to assist a physician with an on-line system for accurately determining when to give a patient a blood transfusion or otherwise alter the clinical management of that patient.

Description: SYSTEM FOR MEASURING BLOOD OXYGEN LEVELS Field of the Invention This invention relates to systems and methods for determining levels of control and peripheral blood gases. Specifically, this invention relates to a system and method of determining, in real-time, the partial pressure of oxygen in a patient's mixed venous blood. Background of the Invention One problem that has troubled physicians during the modern medical age is how to accurately measure the oxygenation state of a patient's tissues without resorting to an invasive procedure. This is important during many medical procedures because the physician needs to know when to administer medicaments or transfuse more blood into a patient. When the oxygenation state of a patient's tissues is low, the physician may wish to transfuse more blood or other oxygen carriers to increase the oxygen transportation rate. At the present time, most physicians rely on pulmonary artery catheterization to directly measure the oxygenation state of their patient's mixed venous blood during surgery. The physician then infers how well the patient's tissue is oxygenated from the measured oxygen content of the blood. A physician can infer the oxygen state of the patient's tissue by knowing the partial pressure of oxygen in the mixed venous blood (Pv0 2 , also known as mixed venous blood oxygen tension) because of the equilibrium that exists between the partial pressure of oxygen (P0 2 ) in the venous blood and the tissue. As arterial blood passes through the tissues, a partial pressure gradient exists between the P0 2 of the blood in the arteriole entering the tissue and the tissue itself. Due to this pressure gradient, oxygen is released from hemoglobin in the red blood cells and also from solution in the plasma; the released 0 2 then diffuses into the tissue. The P0 2 of the blood issuing from the venous end of the capillary cylinder will be a close reflection of the P0 2 at the distal (venous) end of the tissue through which the capillary passes. Under normal conditions the blood P0 2 is essentially the same as that of interstitial fluid in contact with the outside of the capillary. The degree of equilibration between blood and tissue may depend on the speed of passage of blood through the capillary bed. If the blood moves through the capillary bed too quickly, the 0 2 may not have time to diffuse into the tissues. It has also been argued that, under conditions of critical oxygen delivery caused by extreme anemia, there may not be time for equilibration of tissue and the partial pressure of oxygen in the blood. These situations may lead to higher than expected Pv0 2 . Nevertheless, in the clinical situation, it is generally accepted that the most reliable single physiological indicator for monitoring the overall balance between oxygen supply and demand is Pv0 2 . As discussed above, one mechanism for determining the Pv0 2 is through insertion of a pulmonary artery catheter that is passed through the right atrium and the right ventricle of the heart before entering the pulmonary artery by passage through the pulmonary valve. To fully assess whole body oxygen transport and delivery, one catheter is placed in the patient's pulmonary artery and another in a peripheral artery. Blood samples are then drawn from each catheter to determine the pulmonary artery and arterial blood oxygen levels. The patient's cardiac output may be obtained using the pulmonary arterial catheter by utilizing thermodilution techniques. By injecting a known quantity of a sterile solution at a known temperature into the right atrium of the heart, and then measuring the resultant change in blood temperature in the pulmonary artery, a physician can determine the cardiac output of the patient. While these procedures have proven to be somewhat accurate, they are also quite invasive. For example, use of devices such as the Swan-Ganz ® thermodilution catheter (Baxter International, Santa Ana, CA) can lead to an increased risk of infection, pulmonary artery bleeding from pneumothorax and other complications. Another method of determining the oxygenation level of a patient's tissue is to measure the level of circulating hemoglobin in the blood. (P. Lundsoaard-Hansen. Iπfusionstherapie (1989) 16:167-175.) If the hemoglobin level per deciliter of blood in the patient is high, the physician can infer that the patient has sufficient capacity to carry oxygen to the tissue. During an operation this value is often used as a trigger; i.e. if the value falls below a certain point additional blood is given to the patient. Unfortunately, measuring the hemoglobin level in a patient only yields a rough estimate of how well the patient's tissues are actually oxygenated. The patient's cardiac output is also an important factor in correlating hemoglobin levels with tissue oxygenation states. Cardiac output or CO is defined as the volume of blood ejected by the left ventricle of the heart into the aorta per unit of time (ml/min) and can be measured with a thermodilution catheter. For example, if a patient has internal bleeding, the concentration of hemoglobin in the blood might be normal, but the total volume of blood will be low. In this situation, due to the inadequate venous return of blood to the heart, the cardiac output decreases to provide better circulation to the tissues. For this reason, simply measuring the amount of hemoglobin in the blood without measuring other parameters such as cardiac output is not always sufficient for estimating the actual oxygenation state of the patient. However, in spite of this a majority of physicians still rely on hemoglobin measurements to gauge whether the patient's oxygenation is stable during surgery because other methods are too invasive. The Fick equation (Fick, A. Wurzburg. Phvsikalisch edizinische Gesellschaft Sitzunosbericht 16 (1870)) relates the arterial oxygen concentration, venous oxygen concentration and cardiac output to the total oxygen consumption of a patient and can be written as: (Ca0 2 - Cv0 2 ) x CO - V0 2 where Ca0 2 is the arterial oxygen content, Cv0 2 is the venous oxygen content, CO is the cardiac output and V0 2 represents whole body oxygen consumption. The V0 2 level can be calculated from the difference between inspired and mixed expired oxygen and the volume of ventilation. Others have attempted to non-invasively infer cardiac output by measuring arterial blood pressure instead of relying on thermodilution catheters. For example, Kraiden et al. (U.S. Patent No. 5,183,051) use a blood pressure monitor to continuously measure arterial blood pressure. These data are then converted into a pulse contour curve waveform. From this waveform, Kraiden et al. calculate the patient's cardiac output. During hemodilution, either intentionally as part of an autologous blood conservation regimen, or following surgical bleeding with maintenance of normovolemia, Hb concentration and Ca0 2 decrease. As the red cell concentration falls, a reduction in whole blood viscosity occurs. This factor, together with the simultaneous increase in venous blood return, causes a rise in CO. The rise in CO results in improved 0 2 transport to the tissues (D0 2 ). The degree to which this physiological compensation occurs primarily depends on the CO response to the reduction in red cell mass. Some authorities have concluded that the relationship between a decrease in Hb concentration and increase in CO is linear (Fan et al, Am. J. Phvsiol. 1980; H545-H552; Robertie and Gravlee, International Anesthesioloαv Clinics 1990 28(4): 197-204), whereas others have maintained that it follows a curvilinear relationship (Lundsgaard-Hansen, P., Vox. Sana. 1979, 36:321-336). However, the degree of curvature found was very minimal, leading many researchers to perform calculations that assume a linear relationship (Hint, H., Acta Anaesthesiolooica Bejgjca 1968, 2:119-138). In man, the extent to which CO rises as Hb concentration decreases can vary between 0.25 to 0.70 L/min/g decrease in Hb. Hence, the cardiac output response to hemodilution differs between patients thereby affecting the Hb level at which additional oxygen carrying capacity in the blood is required. The variability of CO response to decreases in Hb is one reason that measuring Hb levels is not a good reflection of a patient's tissue oxygenation level. The necessity for red blood cell transfusions also varies depending on such factors as vascular tone, which will cause the viscosity contribution to total systemic resistance to vary, and the ability of the myocardium to function at low Hb levels. During moderate hemodilution, yocardial blood flow increases proportionately more than total CO and hence, in the absence of significant coronary atherosclerosis, no myocardial ischemia occurs. It has been shown, however, that low postoperative hematocrit (Hct) may be associated with postoperative ischemia in patients with generalized atherosclerosis. Hematocrit is typically defined as the percentage by volume of packed red blood cells following centrifugation of a blood sample. Though a number of researchers have attempted to define a critical Hct level, most authorities would agree that an empirical automatic transfusion trigger, whether based on Hb or Hct should be avoided and that red cell transfusions should be tailored to the individual patient. The transfusion trigger, therefore, should be activated by the patient's own response to anemia rather than any predetermined value. Indeed, for patients under anesthesia it is recommended that in the absence of risks, transfusion is not indicated, independent of hemoglobin level. If Pv0 2 is accepted as a reasonable indicator of patient safety, the question of what constitutes a "safe" level of this parameter arises. Though much data exist on critical oxygen delivery levels in animal models, there is little to indicate what a critical Pv0 2 might be in the clinical situation. The available data indicate that the level is extremely variable. For instance, in patients about to undergo cardiopulmonary bypass, critical Pv0 2 varied between about 30 mm Hg and 45 mm Hg (Shibutani et al, Crit. Care ed. 1983, 11(8):640-643); the latter value is well within the range of values found in normal, fit patients. Furthermore, shunting of blood in the tissues will cause elevated levels of Pv0 2 , such as is found in patients in septic shock, and will result in 0 2 supply dependency (Moshenifar et al, CHEST 1983, 84(3): 267-271). A Pv0 2 value of 35 mm Hg or more may be considered to indicate that overall tissue oxygen supply is adequate, but this is implicit on the assumption of an intact and functioning vasomotor system. This Pv0 2 level is reached at a Hb of about 4 g/rJL in patients with good cardiopulmonary function. During surgery it is necessary to maintain a wide margin of safety and probably best to pick a Pv0 2 transfusion trigger at which the patient is obviously in good condition as far as oxygen dynamics are concerned. In practice, only certain patients will be monitored with a pulmonary artery catheter. Accordingly, Pv0 2 will not be available for all patients, leaving the majority to be monitored with the imperfect trigger of Hb concentration. Efforts to resolve these problems in the past have not proven successful. For example, Faithfull et al. (Oxyoen Transport to Tissue XVI. Ed. M. Hogan, Plenum Press, 1994, pp. 4149) describe a model to derive the oxygenation status of tissue under various conditions. However, the model is merely a static simulation allowing an operator to gauge what effect changing various cardiovascular or physical parameters will have on tissue oxygenation. No provisions are made for continuous data acquisition and evaluation to provide a dynamic representation of what may actually be occurring. Accordingly, the model cannot be used to provide real-time measurements of a patient's tissue oxygenation under changing clinical conditions Therefore, a need exists for a system to accurately assess, in real-time, the Pv0 2 of a patient. Summary of the Invention A system and procedure has been developed to predict, in real-time, a patient's PvO, under a variety of clinical conditions. This system can advantageously replace hematocrit or hemoglobin measurements, which are often inaccurate, as an indicator of the patient's oxygenation levels. The system, known throughout the instant application as "Oxyflow," unexpectedly uses multiple, relatively non-invasive, patient derived inputs to provide real-time calculations of Pv0 2 . In deriving the desired Pv0 2 value, the system measures CO, preferably derived from an arterial pressure signal taken from the patient. A system such as the Modelflow™ system (TNO-Biomedical Instrumentation, Amsterdam) can be used in conjunction with the present invention to provide the CO measurement continuously in real-time. The system also determines the arterial oxygen content (Ca0 2 ) of the patient. Preferably a blood chemistry monitor that can continuously measure arterial blood gases and hemoglobin concentrations is used to provide, in real time, the measurements needed to determine (Ca0 2 ). Additionally, the oxygen consumption of the patient (V0 2 ) is determined, preferably by gas analysis or metabolic rate. It must be emphasized that, while preferred embodiments of the invention include a blood chemistry monitor and/or pressure transducers, they are not essential components of the disclosed apparatus and are not necessary for practicing the disclosed methods. For example, a physician could manually measure blood gas levels, body temperatures and Hb concentrations and then enter this information into the Oxyflow system via the keyboard. From the values obtained (Ca0 2 , V0 2 and CO), the present invention solves the Fick equation [V0 2 - (Ca0 2 - Cv0 2 ) x CO] and calculates the venous oxygen content (Cv0 2 ) of the patient. Once the Cv0 2 has been determined, the Pv0 2 can be calculated using algorithms for calculating the position of the oxyhemoglobin disassociation curve such as the Kelman equations (Keiman, J. Appl. Phvsiol. 1966, 21(4): 1375-1376). Accordingly, one embodiment of the present invention is a method for determining Pv0 2 of a patient in real¬ time. This method includes the steps of: storing oxygenation constants into a first computer memory; measuring the cardiac output values (CO) of a patient in real-time, wherein the cardiac output values are saved to a second computer memory; storing a value corresponding to the whole body oxygen consumption (V0 2 ) of said patient into a third computer memory; determining the arterial oxygen content (Ca0 2 ) of a said patient; and calculating the mixed venous blood oxygen tension (Pv0 2 ) of a patient in real-time. Preferably, the first computer memory discussed in the above method is a random access memory (RAM). Similarly, the second computer memory and third computer memory of the above method are advantageously also random access memories. As will be discussed in more detail below, oxygenation constants are numerical values primarily related to the physical characteristics of oxygen carriers or to the physiological characteristics of the patient. Such oxygenation constants include, but are not limited to, blood volume, oxygen solubility in plasma and the oxygen content of a desired unit of saturated oxyhemoglobin. In preferred embodiments the patient's Ca0 2 will be determined in real time using values obtained from a blood chemistry monitor. Such values typically comprise numerical values corresponding to hemoglobin concentration, arterial oxygen tension (Pa0 2 ), arterial carbon dioxide tension (PaC0 2 ), arterial pH and body temperature of the patient. Preferably the desired values are obtained contemporaneously with the measurement of the cardiac output levels. Another embodiment of the present invention is an apparatus for determining the Pv0 2 of a patient in real¬ time. The apparatus includes: a first computer memory for storing oxygenation constants; an input reflecting the cardiac output (CO) values of a patient in real-time, wherein said cardiac output values are saved in a second computer memory; first instructions for storing a value corresponding to the whole body oxygen consumption (V0 2 ) of said patient into a third computer memory; second instructions for obtaining the arterial oxygen content (Ca0 2 ) of said patient; and third instructions in said memory for calculating the mixed venous blood oxygen tension (Pv0 2 ) of a patient in real-time. For the purposes of this embodiment the oxygenation constants are as described previously. Preferably, the first computer memory, second computer memory and third computer memory are random access memories. In addition, the first computer memory can also advantageously be a computer hard disk. Further, the input reflecting the cardiac output can preferably be obtained from an arterial pressure line, transducers or pressure amplifiers. In another preferred embodiment, the second instructions can be stored in a blood chemistry monitor. Additionally, the second instructions preferably comprise an application of the Fick equation. Preferably the third instructions employ algorithms for calculating the position of the oxyhemoglobin disassociation curve as provided by the Kelmaπ equations. In preferred embodiments, the second instructions may include instructions for obtaining said patient's hemoglobin concentration, arterial oxygen tension (Pa0 2 ), arterial carbon dioxide tension (PaC0 2 ), arterial pH and body temperature. These numerical values may be obtained from a blood chemistry monitor or entered manually. Particularly preferred embodiments employ a blood chemistry monitor to obtain the desired values contemporaneously with the measurement of the cardiac output values. Other objects, features and advantages of the present invention will be apparent to those skilled in the art from a consideration of the following detailed description of preferred exemplary embodiments thereof taken in con- junction with the Figures which will first be described briefly. Brief Description of the Figures FIGURE 1 is diagram of the Oxyflow system including a computer, a converter box, a blood chemistry monitor and a patient. FIGURE 2 is a schematic diagram of the computer system that runs the Oxyflow system. FIGURE 3 is a flowchart detailing the overall software program that runs the Oxyflow system. FIGURE 4 is a schematic diagram of data input and calculations as performed in selected embodiments of the present invention. Detailed Description The present invention is a system and software program called Oxyflow that may be used to accurately predict the Pv0 2 of a patient. This system can be used, for example, during surgery to assist the physician in determining the appropriate time to give a blood transfusion or administer a blood substitute. By continuously calculating the patient's Pv0 2 under a variety of clinical conditions, the system replaces the imperfect hemoglobin measurement as an indicator of tissue oxygenation levels. In a broad aspect the system of the present invention preferably gathers data from the patient and provides a real-time calculation of Pv0 2 . Significantly, the system of the present invention has many advantages over prior measurements of the patient's tissue oxygenation levels. For example, this system does not require a relatively invasive, and potentially dangerous, procedure such as pulmonary artery catheterization to determine Pv0 2 . As explained above, invasive procedures such as pulmonary artery catheterization can lead to numerous complications for the patient. These complications include increased incidents of infection, bleeding of pneumothorax and other complications related to the procedure. This system has several components which, acting together, provide the entire invention. I. SYSTEM OVERVIEW In preferred embodiments the Oxyflow system is an online, real-time monitor of cardiac output (CO) and mixed venous partial pressure of oxygen (Pv0 2 ). Referring now to Figure 1, Oxyflow system 100 provides a physician with real-time data relating to the oxygenation state of a patient. As previously alluded to, the system advantageously works by gathering data from a patient without having to resort to relatively invasive procedures such as pulmonary artery catheterization. As shown in Figure 1, patient 110 is linked to interface box 120 via arterial pressure line 130 and transducers 132 that monitor the patient's arterial pulse wave. The interface box 120 has an RS232 serial port (not shown) which connects to a computer 140 by a serial cable 142. The interface box 120 may also contain an analog to digital converter to convert the analog signal of the arterial pressure output from transducers 132 into a digital signal. This digital signal is then passed to the computer 140 through the serial line 142. The analog signal from arterial pressure line 130 is normally sampled at 100 Hz with a resolution of 2.5 mV which is sent over the RS232 serial line and thereafter stored in buffers maintained in the computer's memory. The sampled signals are intermittently saved from the computer memory to the hard disk of the computer. The data from arterial pressure line 130 can be used to calculate, as discussed below, the systolic, diastolic and mean pressure, pulse interval, heart rate, blood ejection time for the heart and, ultimately, cardiac output. In addition, a continuous aortic flow signal can be computed by the computer 140 from a simulated model of the aortic input impedance. Data from the arterial pressure signal can also be used to find the left ventricular stroke volume, which can thereafter be integrated for each heart beat to determine the systemic vascular resistance. These computations are stored in a buffer in the computer's memory and then intermittently saved to the computer's hard disk. As discussed below, the cardiac output (CO) is used in the present invention to determine the patient's Pv0 2 . A second RS232 serial port on the back of the interface box 120 receives data from the a second serial cable 144 that has been linked to optional blood chemistry monitor 150. The blood chemistry monitor 150 receives data relaying concentrations of specific components of the patient's arterial blood through an arterial monitoring line 160. The blood chemistry monitor 150 measures concentrations of blood components and physical parameters such as pH, hemoglobin levels, arterial oxygen partial pressure and arterial carbon dioxide partial pressures. One of ordinary skill in the art will realize that the information gathered by the blood chemistry monitor 150 can also be manually entered into the system. For example, a physician can take blood samples from the patient and determine, by standard analysis, the concentrations of the same blood components and physical parameters as measured by the blood chemistry monitor 150. The values can then be entered into the Oxyflow system through the keyboard. The arterial monitoring line 160 repeatedly samples the patient's blood and transmits these specimens to the sensors of the blood chemistry monitor 150. One preferred blood chemistry monitor is the VIA 1-01 monitor (VIA Medical, San Diego, CA). However, other similar types of blood chemistry monitors are anticipated to work in the same manner. Tyiπg all these hardware components together is the Oxyflow system software. The software controls data gathering from the arterial pressure line 130 and blood chemistry monitor 150. These data are then used to derive the partial pressure of oxygen in the mixed venous blood to provide a real-time, accurate read out for the physician. More specifically, the Oxyflow software gathers arterial pressure data from the patient and uses these data to determine the patient's cardiac output. The actual method used to determine CO is not critical and the relevant data may be obtained using a variety of means. Accordingly, those skilled in the art will appreciate that any relatively non-invasive cardiac output measurement device may be used in conjunction with the present invention. In preferred embodiments the cardiac output determination can be made using the Modelflow software or methods such as those described in U.S. Patent No. 5,183,051 to Kraiden. Along with the CO, arterial pH, hematocrit (or hemoglobin) levels, Pa0 2 , PaC0 2 and body temperature may be determined, preferably from the blood chemistry monitor input. Such values are useful in determining arterial oxygen content (Ca0 2 ). Those skilled in the art will appreciate that the blood chemistry monitor can continually sample the patient's arterial blood at set time points to identify changes in blood gas/chemistry levels. If a change has taken place in any of the values measured by the blood chemistry monitor, the new value may be transmitted to the computer allowing a new arterial oxygen content to be determined. In addition to the cardiac output, the total oxygen consumption (V0 2 ) of the patient can be assumed or determined through standard means known to those skilled in the art. For example, the Physioflex system from Physio Medical Systems (HAARLEM, Netherlands) can be used to measure the V0 2 of a patient. In any case, after V0 2 , cardiac output (CO), and arterial oxygen content (Ca0 2 ) are determined, the software of the present invention applies these values to the Fick equation so that the mixed venous oxygen content (Cv0 2 ) can be determined. This procedure is explained in more detail below. Once the Cv0 2 is known, the mixed venous oxygen tension (Pv0 2 ) can be derived. Values for mixed venous pH and PC0 2 are assumed to have a constant (but alterable) relation to arterial pH and PaC0 2 respectively and these are used, along with other variables, in the Kelman equations to define the position of the oxyhemoglobin dissociation curve. Knowing the Hb concentration a Pv0 2 is derived that then provides a Cv0 2 (which includes contributions from Hb, plasma and PFC) equal to the Cv0 2 determined from the Fick equation. The Pv0 2 value is then updated in real¬ time so that the physician always knows the oxygenation state of the patient. The method for performing these functions is described in more detail below. II. HARDWARE DESCRIPTION Referring now to Figure 2, an embodiment of the computer system 155 that controls the peripheral blood monitoring system is shown. System 155 can be operated in a stand-alone configuration or as part of a network of computer systems. The system 155 is an integrated system which gathers data from the patient and presents it to the operator. The desktop system 155 includes the Oxyflow blood monitoring software operating in the MS-DOS, version 6.2 or later, operating system, available from Microsoft Corporation, on computer 160. Although this embodiment is described using the MS-DOS environment on a personal computer, other embodiments may use a different operational environment or a different computer or both. In an alternate embodiment of the invention, the computer 160 can be connected via a wide area network (WAN) connection to other physicians or hospitals. A WAN connection to other medical institutions enables a real time review of the patient's progress during surgery or in the intensive care unit. Referring again to Figure 2, the presently preferred system 155 includes a computer 160, having a minimum of an Intel 80486 or similar microprocessor running at 33 MHz. The computer 160 includes a minimum of four megabytes (MB) of RAM memory (not shown). The system 155 includes a hard disk drive 165 connected to the processor 170. The hard drive 165 is optional in a network configuration, i.e., the workstation uses a hard disk or other storage device in a file server. If computer 160 is used in the stand-alone configuration, the hard drive 165 is preferably 100 Mbytes or more. The computer 160 is integrated with a group of computer peripherals, and is connected to a VGA (video graphics array) display standard, or better, color video monitor 175, which is required to use all the features of the system 155. A keyboard 180 that is compatible with IBM AT type computers is connected to the computer 160. A pointing device 185, such as a two or three button mouse can also connect to the computer 160. Reference to use of the mouse is not meant to preclude use of another type of pointing device. The computer 160 connects to a printer 190 to provide a way to produce hard-copy output, such as printouts for file records. In this configuration, a backup device 195, such as a Jumbo 250Mb cartridge tape back-up unit, available from Colorado Memory Systems, is preferably connected to the computer 160. A hard drive 165 or other similar device is required in the stand-alone configuration. In an alternate embodiment of a stand-alone configuration, or as one of the workstations of a network configuration, the system 155 may include a portable computer, such as a laptop or notebook computer, e.g., a Premium Executive 386SX/20, available from AST Research, or other computers available from a plurality of vendors. The portable computer (not shown) is equipped with components similar to that described in conjunction with computer 160. It will be understood by one skilled in the technology that a programmed computer can also be implemented completely or partially with custom circuitry. Therefore, the chosen implementation should not be considered restrictive in any matter. III. Software Overview As discussed above, the Oxyflow system of the present invention gathers data from a patient and determines the mixed venous blood oxygen tension (Pv0 2 ) of a patient in real-time. Referring now to Figure 3, the process is begun when a start signal is transmitted by the user to the system at start state 200. The start signal can be a keystroke of mouse command that initiates the software to begin gathering data. After receiving the start command at state 200, arterial pressure data is gathered from a patient at state 202. Arterial pressure data is gathered by hooking a patient up to an arterial pressure monitor by standard means known to those of skill in the art. Once data have been gathered from a patient at state 202, a "data in range" decision is made at decision state 204. At this stage, the software compares the data gathered at state 202 with known appropriate ranges for arterial pressure values. Appropriate ranges for arterial pressure data are, for example, between 70/40 and 250/140. If data gathered at process step 200 are not within the range programmed in decision state 204, an error/exception handling routine is begun at state 206. The error handling routine at state 206 loops the software back to process step 202 to re-gather the arterial pressure data. In this manner, false arterial pressure data readings will not be passed to the rest of the program. If the data gathered at process step 202 are in the appropriate range at decision state 204, the software pointer moves to process step 208 that contains instructions for gathering arterial data. Preferably the collected data will include patient temperature, arterial pH, hemoglobin levels, Pa0 2 and PaC0 2 . Moreover, the data is preferably generated by an attached blood chemistry monitor. In such embodiments the data is gathered by receiving data streams via the serial connection from the blood chemistry monitor into the computer. Alternatively, the relevant values may be obtained from accessing data that is manually input from the keyboard. As described previously, the blood chemistry monitor continually samples arterial blood from the patient preferably determining several properties of the patient's blood from each sample. Data corresponding to each of the properties taken from the blood chemistry monitor at process step 208 are checked so that they are in range at decision state 210. An appropriate range for the pH is 7.15 to 7.65. An appropriate range for the hemoglobin level is from 0 to 16 g/dL. An appropriate range for the Pa0 2 is from 50 mm Hg to 650 mm Hg while an appropriate range for the PC0 2 is from 15 mm Hg to 75 mm Hg. If data are not within the appropriate ranges for each specific variable at decision state 210, an error/exception handling routine at state 212 is begun. The error/exception handling routine at state 212 independently analyzes variables gathered at state 208 to determine whether it is in range. If selected variables gathered at state 208 are not within the appropriate range, the error/exception handling routine 212 loops a software pointer back to state 208 so that accurate data can be gathered. If the selected data are in range at decision box 210, the software then derives the Ca0 2 value along with the cardiac output (CO) from the previously obtained arterial pressure data at state 214. As discussed, cardiac output can be derived from arterial pressure measurements by any number of methods. For example, the Modelflow system from TNO Bio edical can derive a cardiac output value in real-time from an arterial pressure signal. Other methods, as discussed above, could also be used at process step 214 to determine cardiac output. Once a cardiac output value has been determined at process step 214, the V0 2 of the patient is measured or input at state 216. The patient's V0 2 can be calculated using the methods previously described or measured by hooking the patient up to a suitable ventilator and measuring his oxygen uptake through a system such as the Physioflex discussed above. By determining the amount of oxygen inspired and expired, the ventilator may be used to calculate the total amount of oxygen absorbed by the patient. After the patient's V0 2 value has been determined at process step 216, these variables are applied to the Fick equation at state 218 to provide a real time Cv0 2 . The Fick equation is provided above. Once the Cv0 2 is known, the mixed venous oxygen tension (Pv0 2 ) can be derived at state 220. As previously explained, values for mixed venous pH and PC0 2 are assumed to have a constant (but alterable) relation to arterial pH and PaC0 2 respectively and these are used, along with other variables, in the Kelman equations to define the position of the oxyhemoglobin dissociation curve. Knowing the Hb concentration a Pv0 2 is derived that then provides a total Cv0 (which includes contributions from Hb, plasma and PFC) equal to the Cv0 2 determined from the Fick equation. If the Cv0 2 value will not "fit" the Fick equation, another Pv0 2 value is chosen. This process is repeated until the Fick equation balances and the true Pv0 2 is known. After deriving the Pv0 2 of the patient's blood, it is displayed on the computer screen at step 222. If the software has not received a keyboard or mouse input to stop gathering data at decision state 224, a pointer loops the program back to process state 202 to begin gathering arterial pressure data again. In this manner, a real-time data loop continues so that the patient's mixed venous partial pressure of oxygen is constantly updated and displayed on the computer at state 222. If the software has received a stop command from a keyboard or mouse input at decision state 224, then a finish routine 226 is begun. IV.Software Implementation Many different ways of implementing the software of the present invention will be known to those with ordinary skill in the art. For example, programming languages such as C+ +, Basic, Cobol, Fortran or Modula-2 can be used to integrate the features of the present invention into one software package. An alternative method of producing the software of the present invention is to use a spreadsheet program to gather and determine the Pv0 2 of a patient in real-time. This method is described in detail below. The following system utilizes a large Microsoft Excel® spreadsheet to gather information from the patient and derive the Pv0 2 . Before receiving real-time inputs of cardiovascular and oxygenation variables, a number of oxygenation constants may be entered into the system. These constants preferably include the patient's blood volume, oxygen solubility in plasma and the oxygen content of 1 g of saturated oxyhemoglobin. The oxygenation constants are then stored in the computer's memory for use in later calculations. TABLE 1 shows commands from part of a Microsoft Excel ® spreadsheet that gathers a patient's data and derives the value of Pv0 2 . The program is initialized by assigning names to various oxygenation constants that are to be used throughout the software. In the embodiment shown oxygenation constants corresponding to blood volume (BV), oxygen solubility in a perfluorocarbon emulsion (02S0L), specific gravity of any perfluorocarbon emulsion (SGPFOB), intravascular half-life of a perfluorocarbon emulsion (HL), weight/volume of a perfluorocarbon emulsion (CONC), barometric pressure at sea level (BARO), milliliters oxygen per gram of saturated hemoglobin (HbO) and milliliters of oxygen per 100ml plasma per 100mm of mercury (PIO) are all entered. An example of starting values for Kelman constants, a subset of the oxygenation constants, is also shown in TABLE 1. These starting values are used in later calculations to derive the patient's mixed venous oxygenation state. As with the other oxygenation constants the Kelman constants are also assigned names as shown in TABLE 1. TABLE 1 ASSUMPTIONS: VALUES AT START: Blood Volume (ml/kg) -BV 70 0 2 solubility in PFB (ml/dl @37 deg C) 02S0L 52.7 Specific Gravity of PFOB -SGPFOB 1.92 Intravascular half-life of Oxygeπt HT (hours) -HL - 1/2 Life of 0- Wgt/Vol of PFOB emulsion/100 -CONC 0.6 Barometric Pressure @ sea level -BARO 760 Ml 02 per gram saturated Hb -HbO 1.34 Ml 02 per 100 ml plasma per 100 mm Hg -HIO 0.3 After the oxygenation constants, including the Kelman constants have been assigned names, real time inputs from the arterial pressure lines and blood chemistry monitor may be initialized and begin providing data. As shown in TABLE 2, the system depicted in this embodiment receives data relating to the arterial oxygen saturation percentage (Sa0 2 ) and mixed venous oxygen saturation percentage (Sv0 2 ) . In particular, saturation percentages are derived from arterial and venous data for oxygen tension (Pa0 2 and Pv0 2 ) , pH (pHa and pHv) , carbon dioxide tension (PaC0 2 and PvC0 2 ) and body temperature (TEMP) . As previously discussed, values for PvC0 2 and pHv are related, by a fixed amount, to those of PaC0 2 and pHa respectively. Cardiac output (CO) is also input as is V0 2 . Figure 4 provides a schematic representation of this procedure and resulting data. When Hb concentration, arterial and mixed venous blood gas and acid/base parameters are entered (automatically or manually) into the program, the 0 2 delivery and consumption variables for both red cell containing Hb and for the plasma phase may be determined. Those variables relating to PFC or Hb based oxygen carrier can also be determined. Referring again to Figure 4, numerical values useful for the calculation of Ca0 2 relate to Hb concentration, arterial oxygen tension (Pa0 2 ) , arterial carbon dioxide tension (PaC0 2 ) , arterial pH (pHa) and body temperature. The position of the oxyhemoglobin dissociation curve is calculated using the Kelman equations, which are input as oxygenation constants in the program. These calculations produce a curve that, over the physiological range of 0 2 tensions, is indistinguishable from the parent curve proposed by Severinghaus (J. AΌPI. Phvsiol. 1966, 21: 1108-1116) . As shown schematically in Figure 4, iteration may be used to calculate a Pv0 2 that results in the required mixed venous oxygen contents in Hb, plasma and fluorocarbon to satisfy the Fick equation. TABLE 2 INPUTS: AT START: Hemoglobin (Gm/dl) -Hb 6 Desired End Hemodilution Hb -HbEND 15 Arterial Oxygen Saturation (%) -Sa02 Calculated Arterial Oxygen Saturation 1%) -Sa02CALC - 100 * (SPa02 * (SPa02 * |SPa02 * (SPa02+Ka3)+Ka2)+Ka1))/(SPa02*(SPa02 * (SPa02*(SPa02+Ka7)+Ka6)+Ka5)+K Active Input Value for Sa02 -Sa02USED -IF(Sa02< >0,Sa02,Sa02CALC) GO CD Mixed Venous Oxygen Saturation (%) -Sv02 Calculated Mixed Venous Oxygen saturation • SV02CALC -100 * (SPv02*(SPv02*(SPv02 , (SPv02+Ka3)+Ka2)+Ka1))/SPv02*(SPv02 * (SPv02*(SPv02+Ka7)+Ka6)+Ka5)+K Active Input Value for Sv02 -Sv02USED -IF(Sv02< >0,Sv02,Sv02CALC) Arterial Oxygen Partial Pressure (mm Hg) -Pa02 100 Calculated 'standardized' Pa02 -SPa02 -Pa02 * 10 A ((0.024*(37-TEMPUSED))+(0.4 * (pHaUSED-7.4))+(0.06*(L0G10(40|-LOG10|PaCO2USED|))) Active Input Value for PaS02 -PaS02USED -IF(Pa02< >0,Pa02,SPa02) Arterial pH -pHa Normal Arterial pH -pHaNORM 7.4 Active Input Arterial pH -pHaUSED -IF(pHaO0,pHa,pHaN0RM) Arterial PC02 -PaC02 Normal PaC02 -PaC02N0RM 40 Active Input Arterial PC02 -PaC02USED ■ IF(PaC02< >0,PaC02,PaC02N0RM) Body Temp C -TEMP Normal Body Temp C -TEMPNORM 37 Active Input Body Temp C -TEMPUSED -IF(TEMP < >0,TEMP,TEMPN0RM) | Mixed Venous Oxygen Partial Pressure (mm Hg) -Pv02 | 40.6819722973629 Calculated 'standardized' Pv02 -SPv02 •Pv02 < 10"((0.024*(37-TEMPUSED))+(0.4*(pHvUSED-7.4))+(0.06*(LOG10(40)-LOG10(PvC02USED)))) Mixed Venous pH -pHv Normal Venous pH 7.4 Active Input Mixed Venous pH -pHvUSED -IF(pHv< >0,pHv,pHvNORM) Mixed Venous PC02 -PvC02 Normal Mixed Venous PC02 -PvC02N0RM 40 Active Input Mixed Venous PC02 -PvC02USED -IF(PvC02 < >0,PvC02,PvC02N0RM) Cardiac Output (l/mm) -CO -((14 - Hemoglobin (gm/dl) * CO Response to 1 gram of Hb Depletion) +5 CO Response to 1 gr Hb depletion -COCHG 0.7 Intravascular Oxygent HT Dose(ml/kg) -PFB GO Time Adj. Intravascular Oxygent HT Coπc(ml/kg) -TAPFB CD GO Patient's Weight (kg) -kg 70 Total 02 Consumption (ml/miπ/kg) -V02KG 3 Calculated Blood Volume (ml) -CBV -BV*kg m GO Calc input Total 02 Consumption (ml/min/kg) -V02 -kg * V02KG m Bleeding Rate (liters/hour) -BR 1 Exchange Volume (ml) -EV 100 _3 cz TABLE 3 DESCRIPTION: CALCULATIONS: Arterial 02 Content in Hemoglobin (ml/dl) -Ca02Hb -((Hb*HbO*Sa02USED)/100) Arterial 02 Content in Plasma (ml/dl) -Ca02PI -((Pa02*PI0)/100) Arterial 02 Content in PFB (ml/dl) -Ca02PFB -(|PFB*kg*CONC)/SGPFOB|/|kg*BV*0.01)*((02SOL*Pa02)/(100*BARO)) Arterial Oxygen Content (ml/dl) -Ca02 -(Ca02Hb+Ca02PI+Ca02PFB) Mixed Venous 02 Content in Hemoglobin (ml/dl) -Cv02Hb -((Hb*Hb0 * Sv02USED)/100) Mixed Venous 02 Content in Plasma (ml/dl) -Cv02PI -|(Pv02 * PIO)/100) Mixed Venous 02 Content in PFB (ml/dl) -Cv02PFB -((PFB*kg * CONC)/SGPFOB)/(kg * BV * 0.01) * ((O2SOL * Pv02)/(100 * BARO|) Mixed Venous Oxygen Content (ml/dl) -Cv02SUM -(Cv02Hb+Cv02PI+Cv02PFB| Mixed Venous Oxygen Content (ml/dl) -Cv02 - IRCV02SUM > 0,(CV02SUM),Cv02CALC2) Mixed Venous 02 Content (ml/dl) -Cv02CALC2 -Ca02-(V02/(C0*10)) Total Blood loss (ml) - TBL GO Autologous Hb Available (grams)-AHbA CZ CD Autologous Hb Available (grams) in 1st unit-AHbA1 -C105 GO Autologous Hb Available (grams) in 2nd unit-AHbA2 -IF(0FFSET(Hb,0,8) < -OFFSET(HbEND,0,8),* * ,C106-C105) Autologous Hb Available (grams) in 3rd unit-AHbA3 -IF(OFFSET|Hb,0,12)< -OFFSET(HbEND,0,12),* * ,C107,B106,B105) Autologous Hb Available (grams) in 4th unit-AHbA4 - IF(0FFSET(Hb,0, 16) < - OFFSET(HbEND,0, 16),",C 108,B107,B 106.B 105) GO Autologous Hb Available (grams) in 5th unit-AHbAδ _c -IF(OFFSET(Hb,0,20)< -OFFSET(HbEND,0,20),",C109,B108,B107,B106,B105) Autologous Hb Available (grams) in 6th unit-AHbA6 -IF(OFFSET(Hb,0,24)< -OFFSET(HbEND,0,24), * *,C110,B109,B108,B107,B106,B105) Autologous Hb Available (grams) in 7th unit-AHbA7 -IF(OFFSET(Hb,0,28)< -OFFSET(HbEND,0,28),**,C111,B110,B109,B108,B107,B106,B105) Autologous Hb Available (grams) in 8th unit-AHbA8 -IF(OFFSET(Hb,0,32)< -OFFSET(HbEND,0,32), ** ,C112,B111,B110,B109,B108,B107,B106,B105) Autologous Hb Available (grams) in 9th uπit-AHbA9 -IF(OFFSET(Hb,0,36) < -OFFSET(HbEND,0,36),**,C113,B112,B111.B110,B109,B108,B107,B106,B105| ro Autologous Hb Available (grams) in 10th unit-AHbAIO -IF(OFFSET(Hb O,40) < -OFFSET(HbEND,0,40),**,C114,B113,B112,B111,B110,B109,B108,B107,B106,B105) CD Percent of V02 provided from plasma ■ (0 2 Used From Plasma / Active Input Total 0 2 Consumption) * 100 Percent V02 provided by PFB ■ 100 * (0 2 Used From Perflubron / Active Input Total 0 2 Consumption) Percent of V02 provided by plasma and PFB • 100 * ((0 2 Used From Plasma + 0 2 Used From Perflubron / Active Input Total 0 2 Consumption) * 100 Based on the numerical values provided the program calculates and presents the Pv0 2 in real time as shown in TABLE 2. As previously alluded to, this value can help the physician determine when to give the patient a blood transfusion or in other ways alter the patient's clinical management. TABLE 3 and TABLE 4 show additional information that may be provided by the instant invention further demonstrating its utility and adaptability. More specifically, TABLE 3 provides various oxygenation values that may be calculated using the methods disclosed herein while TABLE 4 provides other indices of oxygen consumption and oxygen delivery that are useful in optimizing patient treatment. A closer examination of TABLE 3 shows that the system of the present invention may be used to provide the individual oxygen content of different constituents in a mixed oxygen carrying system. In particular, TABLE 3 provides calculations that give the arterial or venous oxygen content of circulating hemoglobin, plasma and fluorochemical respectively. Such values would be of particular use when intravenously introducing fluorochemical emulsion blood substitutes in conjunction with surgical procedures. The amount of blood that must be removed in order to hemodilute a patient to a certain Hb concentration can be calculated and the amount of Hb present in individual blood "units" removed during the hemodilution procedure are also shown in TABLE 3. TABLE 4 illustrates that the present invention may also be used to provide real time information regarding oxygen consumption and delivery. As mentioned previously, Hb or Hct measurements are not a suitable reflection of tissue oxygenation. This is mainly because they only give an indication of the potential arterial 0 2 content (Ca0 2 ) , without providing information about the transport of that 0 2 (D0 2 ) to the tissues where it is to be used. However as seen in TABLE 4 the instant invention solves this problem by providing on line oxygen transport information which is derived based on Ca0 2 and cardiac output (CO) . More particularly, preferred embodiments of the invention may be used to provide real time D0 2 , arterial blood gases and CO (and all other hemodynamic data already discussed such as BP, Heart Rate, Systemic Vascular Resistance and Cardiac Work) . As shown in TABLE 3, such embodiments can also provide separate readouts of contributions of Hb, plasma and PFC (if in the circulation) to D0 2 . Such data would be particularly useful in both the OR and ICU for providing a safety cushion with respect to the oxygenation of the patient. That is, a decrease in D0 2 , which can be caused by hypoxia, anemia or inadequate CO, would be displayed and immediate indications of the reason for the decrease would be apparent. Accordingly, the caregiver could take appropriate actions to rectify the situation much earlier and with a firmer diagnosis that has heretofore been possible. Moreover, the importance of maximizing D0 2 for certain patients in the ICU has been underscored by recent studies. The present invention may also be used for determining when such intervention is indicated and to provide the data necessary for achieving the desired results. Once D0 2 is known it is possible to calculate the maximum 0 2 consumption (V0 2 ) that could be supported for a certain fixed (and alterable) Pv0 2 . For instance, a Pv0 2 of 36 mm Hg might be chosen for a healthy 25 year old patient, where as a Pv0 2 of 42 mm Hg or higher might be needed for an older patient with widespread arteriosclerosis or evidence of coronary atheroma or myocardial ischemia. Oxygen consumption under anesthesia is variable, but almost always lies in the range of 1.5 to 2.5 ml/kg/min. If the supportable V0 2 , at the chosen Pv0 2 , was well above this range all would be well and no intervention would be necessary. The closer the supportable V0 2 to the normal V0 2 range the earlier intervention could be considered. By use of large V0 2 databases compiled from patients under surgery, appropriate safe ranges of Pv0 2 could be readily determined. As explained, the present system allows a physician to determine the tissue oxygenation state of a patient, in real time, during surgery. Moreover, the present invention provides for the on line monitoring of oxygen consumption in tissues and allows for the optimization of oxygen transport. In the exemplary embodiments described above, the present invention employs a Microsoft Excel ® spreadsheet. However, one of ordinary skill in the art could integrate the above- referenced spreadsheet with the Modelflow system and still be within the purview of the present invention. For example, software instructions written in other languages such as C++, Cobol, Fortran and basic could also carry out similar functions to the Excel ® spreadsheet disclosed herein. The present invention is therefore not limited to the embodiment of the Oxyflow system disclosed herein. Rather, the scope of the invention is to be determined only by the appended claims and reasonable equivalents thereof.

Claims: We Claim: 1. A method for determining the partial pressure of oxygen in the mixed venous blood (Pv0 2 ) of a patient in real¬ time, comprising the steps of: storing oxygenation constants into a first computer memory; measuring the cardiac output values (CO) of a patient in real-time, wherein the cardiac output values are saved to a second computer memory; storing a value corresponding to the whole body oxygen consumption (V0 2 ) of said patient into a third computer memory; determining the arterial oxygen content (Ca0 2 ) of a said patient; and calculating the mixed venous blood oxygen tension (Pv0 2 ) of a patient in real-time. 2. The method of Claim 1 wherein said oxygenation constants comprise numerical values corresponding to blood volume, oxygen solubility in plasma and oxygen content of a desired unit of saturated oxyhemoglobin. 3. The method of Claim 1 wherein arterial oxygen content is determined using numerical values corresponding to hemoglobin concentration, arterial oxygen tension (Pa0 2 ) , arterial carbon dioxide tension (PaC0 2 ) , arterial pH and body temperature of the patient. 4. The method of Claim 3 wherein said numerical values are determined contemporaneously with said measurement of the cardiac output levels. 5. The method of Claim 1 wherein said first computer memory is a random access memory. 6. The method of Claim 1 wherein said second computer memory is a random access memory. 7. The method of Claim 1 wherein said third computer memory is a random access memory. 8. The method of Claim 1 wherein said determining step utilizes a blood chemistry monitor. 9. . The method of Claim 1 wherein said calculating step comprises an application of the Fick equation. 10. An apparatus for determining the Pv0 2 of a patient in real-time, comprising: a first computer memory for storing oxygenation constants; an input reflecting the cardiac output (CO) values of a patient in real-time, wherein said cardiac output values are saved in a second computer memory; first instructions for storing a value corresponding to the whole body oxygen consumption (V0 2 ) of said patient into a third computer memory; second instructions for obtaining the arterial oxygen content (Ca0 2 ) of said patient; and third instructions in said memory for calculating the mixed venous blood oxygen tension (Pv0 2 ) of a patient in real-time. 11. The apparatus of Claim 10 wherein said oxygenation constants comprise numerical values corresponding to blood volume, oxygen solubility in plasma and oxygen content of a desired unit of saturated oxyhemoglobin. 12. The apparatus of Claim 10 wherein said second instructions comprise obtaining the arterial oxygen content using numerical values corresponding to hemoglobin concentration, arterial oxygen tension (Pa0 2 ) , arterial carbon dioxide tension (PaC0 2 ) , arterial pH and body temperature of the patient. 13. The apparatus of Claim 12 wherein said second instructions comprise solving the Fick equation. 14. The apparatus of Claim 10 wherein said first computer memory is a random access memory. 15. The apparatus of Claim 10 wherein said second computer memory is a random access memory. 16. The apparatus of Claim 10 wherein said third computer memory is a random access memory. 17. The apparatus of Claim 10 wherein said computer memory is a hard disk. 18. The apparatus of Claim 10 wherein said input is an arterial pressure line. 19. The apparatus of Claim 10 wherein said second instructions are stored in a blood chemistry monitor. 20. The apparatus of Claim 10 wherein said third instructions comprise an application of the Kelman equation. 21. The apparatus of Claim 10 wherein said second instructions comprise instructions for obtaining said patient's hemoglobin concentration, arterial oxygen tension (Pa0 2 ) , arterial carbon dioxide tension (C0 2 ) , arterial pH and body temperature from a keyboard input. 22. The apparatus of Claim 10 wherein said second instructions comprise instructions for obtaining said patient's hemoglobin concentration, arterial oxygen tension (Pa0 2 ) , arterial carbon dioxide tension (C0 2 ) , arterial pH and body temperature from a blood chemistry monitor.

Inventors: FAITHFULL NICHOLAS SIMON, RHOADES GLENN, FAITHFULL, NICHOLAS, SIMON, RHOADES, GLENN
Applicants: ALLIANCE PHARMA, FAITHFULL NICHOLAS SIMON, RHOADES GLENN, ALLIANCE PHARMACEUTICAL CORP., FAITHFULL, NICHOLAS, SIMON, RHOADES, GLENN
Application year: 1996
Main classification: A61B5
IPC codes: A61B5