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Tisherman, MD, FACS Philip Barie, MD, FACS Faran Bokhari, MD, FACS John Bonadies , MD, FACS Brian Daley, MD, FACS Lawrence Diebel, MD, FACS Soumitra R. Eachempati, MD, FACS Stanley Kurek, DO Fred A. Luchette, MD, FACS Juan Carlos Puyana, MD, FACS Martin Schreiber, MD, FACS Ronald Simon, MD, FACS
Correspondence: Samuel A. Tisherman, MD, FACS, FCCM Departments of Surgery and Critical Care Medicine University of Pittsburgh 638 Scaife Hall 3550 Terrace Street Pittsburgh, PA 15261 Phone: (412) 647-9914 Fax: (412) 802-3308 E-mail: email@example.com
© 2003 Eastern Association for the surgery of Trauma
Endpoints of Resuscitation
I. STATEMENT OF THE PROBLEM Severely injured trauma victims are at high risk of development of the multiple organ dysfunction syndrome (MODS) or death. To maximize chances for survival, treatment priorities must focus on resuscitation from shock (defined as inadequate tissue oxygenation to meet tissue O2 requirements), including appropriate fluid resuscitation and rapid hemostasis. Inadequate tissue oxygenation leads to anaerobic metabolism and resultant tissue acidosis. The depth and duration of shock leads to a cumulative oxygen debt (1). Resuscitation is complete when the oxygen debt has been repaid, tissue acidosis eliminated, and normal aerobic metabolism restored in all tissue beds. Many patients may appear to be adequately resuscitated based on normalization of vital signs, but have occult hypoperfusion and ongoing tissue acidosis (compensated shock), which may lead to organ dysfunction and death. Use of the endpoints discussed in this guideline may allow early detection and reversal of this state. Without doubt, resuscitation from hemorrhagic shock is impossible without hemostasis. Fluid resuscitation strategies prior to obtaining hemostasis in patients with uncontrolled hemorrhage, usually victims of penetrating trauma, remain controversial. No fluid resuscitation may lead to death from exsanguination, whereas aggressive fluid resuscitation may “pop the clot” and lead to more bleeding. “Limited”, “hypotensive”, and/or “delayed” fluid resuscitation may be beneficial, but clinical trials have yielded conflicting results (2,3). This clinical practice guideline will focus on resuscitation after achieving hemostasis and will not address the issue of uncontrolled hemorrhage further. The traditional markers of “successful” resuscitation, including restoration of normal blood pressure, heart rate, and urine output, remain the standard of care per the Advanced Trauma Life Support Course (4). When these parameters remain abnormal, i.e., uncompensated shock, the need for additional resuscitation is clear. After normalizing these parameters, up to 85% of severely injured trauma victims still have evidence of inadequate tissue oxygenation based on findings of an ongoing metabolic acidosis or evidence of gastric mucosal ischemia (5,6). This condition has been described as compensated shock. Recognition of this state and its rapid reversal are critical to minimize risk of MODS or death. Consequently, better markers of adequate resuscitation for severely injured trauma victims are needed. Goals of the Guideline 1) To demonstrate that the proposed endpoint(s) is (are) useful for stratifying the patients’ severity of physiologic derangement. 2) To demonstrate that the proposed endpoint(s) is (are) useful for predicting risk of development of MODS or death. 3) To determine the endpoint(s) for resuscitation that would predict survival without organ system dysfunction if a defined level is achieved within a certain time frame. 4) To improve patient survival and morbidity (organ system dysfunction) by use of appropriate resuscitation endpoint(s). Proposed Endpoints The proposed endpoints of resuscitation fall into 2 categories: global and regional. The global O2 delivery issue has been examined by studies of supranormal O2 delivery and studies of the utility of mixed venous O2 saturation. Other global hemodynamic parameters that have been explored include right ventricular end-diastolic volume, left-ventricular stroke work index, and
© 2003 Eastern Association for the surgery of Trauma
Recommendations Regarding Stratifying Physiologic Derangement Level 1 1. e. The time to normalization of base deficit.. Gastric ischemia can be monitored using gastric tonometry. III. lactate level. other issues to consider for potential resuscitation endpoints include: general availability. Similarly. and risk. The predictive value of the base deficit may be limited by ethanol intoxication or a hyperchloremic metabolic acidosis. cost. 2. Skeletal muscle blood flow is similarly decreased during shock. etc). and the risks of MODS and death. 2. Regional cellular oxygenation can be monitored using near infrared spectroscopy or tissue electrodes. some non-human studies of promising techniques are discussed. Intramucosal pH (pHi) or the gap between intramucosal and arterial PCO2 can be utilized.g. Right ventricular end diastolic volume index (RVEDVI) measurement may be a better indicator of adequate volume resuscitation (preload) than central venous pressure or pulmonary capillary wedge pressure (PCWP). © 2003 Eastern Association for the surgery of Trauma . PROCESS The committee agreed upon the potential endpoints to be considered. Similarly. II. invasiveness. Standard hemodynamic parameters do not adequately quantify the degree of physiologic derangement in trauma patients. From a clinical perspective.Endpoints of Resuscitation Page 3 left-ventricular power output. On the regional level. The initial base deficit. compensated shock disproportionately decreases blood flow to the splanchnic bed to maintain cerebral and coronary blood flow. Literature for review included: human. Medline and EMBASE were searched from 1980 to 2001. speed. RECOMMENDATIONS A. or gastric pHi can be used to stratify patients with regard to the need for ongoing fluid resuscitation. lactate. Persistently high base deficit or low pHi (or worsening of these parameters) may be an early indicator of complications. and pHi is predictive of survival. survival. Intramuscular pH and PCO2 can be monitored. trauma patients. ongoing hemorrhage or abdominal compartment syndrome. Level 2 1. 3. as well as administration of sodium bicarbonate. not just process variables. including packed red blood cells and other blood products. global acid-base status has been explored using base deficit and lactate levels. in addition to direct clinical utility. Some nontrauma studies of critically ill patients were also included particularly if the parameter seemed promising in other surgical patients. Level 3 1. though not part of the main review or recommendations. and some attempted connection between the proposed endpoint and patient outcome (morbidity. Examination of gut-related parameters may be useful as a marker of the severity of shock and also to demonstrate the pathophysiologic connection between gut ischemia and later MODS. The ability of a patient to attain supranormal O2 delivery parameters correlates with an improved chance for survival.
et al (15). The parameters included: CI (>4.5 L/min/m2). reviewed the hemodynamic profiles of high risk surgical patients who survived vs those who did not. finally. 3. blood product replacement.08. In a prospective study of high-risk surgical patients. lactate. O2 delivery. found that resuscitating to supranormal values of cardiac index. Mortality was slightly better at p=0. Patients in both groups had similar goals for preload based on PCWP or RVEDV and hemoglobin. Moore. et al (7. particularly when the values were attained within 24 hours of injury. Serum bicarbonate levels may be substituted for base deficit levels. They then prospectively tested the hypothesis that using the values of survivors as goals for resuscitation rather than the “normal” values for these parameters would improve survival. randomized patients to be resuscitated to the supranormal values above vs standard hemodynamic variables. Oxygen delivery Shoemaker. IV. regardless of group assignment.8). Others have tried to duplicate these findings with limited success. length of stay. Durham. and O2 consumption compared to normal vital signs. In © 2003 Eastern Association for the surgery of Trauma . Patients who did not reach the established goals by 12 hours were at increased risk for developing MODS. using these parameters as goals for resuscitation resulted in decreased complications. Fleming. et al (12). Recommendations Regarding Improved Patient Outcomes Level 1 There is insufficient data to formulate a level 1 recommendation. O2 delivery (>600 mL/min/m2). blood transfusions up to hemoglobin of 14 gm/dL. O2 delivery parameters may be more useful as predictors of outcome than as endpoints for resuscitation. Patients who did not attain the supranormal O2 delivery values were at high risk of developing MODS. The supranormal group had fewer organ failures and shorter hospital stays. and central venous pressure decreased the risk of MODS and death. and hospital costs (9). et al (14).Endpoints of Resuscitation Page 4 2. Measurements of tissue (subcutaneous or muscle) O2 and/or CO2 levels may identify patients who require additional resuscitation and are at risk for MODS and death. and O2 consumption (>170 mL/min/m2). SCIENTIFIC FOUNDATION A. In a randomized trial in victims of severe trauma. Thus. and the use of inotropes and/or vasopressors have not been determined. utilized a resuscitation protocol aimed at maximizing O2 delivery. attempts should be made to increase O2 delivery to normalize base deficit. and. During resuscitation. urine output. Oxygen delivery was augmented by volume loading. B. found that resuscitation to the O2 delivery and/or consumption parameters defined by Shoemaker did not improve the rate of MODS or death compared to conventional parameters. In severely injured patients. followed by dobutamine infusion if necessary. et al (13). The optimal algorithms for fluid resuscitation. Level 2 1. given adequate volume resuscitation. They found that survivors had significantly higher O2 delivery and cardiac index (CI) values than nonsurvivors. this group similarly found that attaining supranormal hemodynamic parameters improved survival and decreased the frequency of organ failures (11). or pHi during the first 24 hours. Bishop. This group then recommended adding to the “ABCs” of resuscitation: “D” for increased delivery of O2 and “E” for ensuring extraction and utilization of O2 by tissues (10).
5-3. Hayes. B. These investigators (5) even found that young victims of penetrating trauma often had evidence of hypoperfusion. Heyland.Endpoints of Resuscitation Page 5 trauma patients. Fourth. followed by enhancement of cardiac output with dobutamine (7. Kern and Shoemaker (21) reviewed all randomized clinical trials of hemodynamic optimization in high-risk patients. The latter group required less fluid for resuscitation. attaining these parameters seemed to be more predictive of survival than useful as goals of resuscitation. control of other aspects of management is variable. entrance criteria vary from one study to another. et al (22). both medical and surgical. found that use of dobutamine to help augment O2 delivery may actually have increased mortality. Outcome was not compared to other endpoints. et al (16). Velmahos.5 L/min/m2). C. Mixed venous oxygen saturation Use of mixed venous O2 saturation (SvO2) levels should reflect the adequacy of O2 delivery to tissues in relation to global tissue O2 demands. Third. and blood transfusions to increase O2 delivery until lactate concentration normalized © 2003 Eastern Association for the surgery of Trauma .8). regardless of group assignment. Thus. Several methodological issues regarding these studies should be noted. They utilized a protocol of volume resuscitation. the protocol consisted of volume loading with crystalloids and blood. The means used to attain the O2 delivery goals may be an important issue that has not been adequately explored. Again. In the original studies by the Shoemaker group. supranormal CI (>4. found that early optimization of O2 delivery parameters did not improve outcome. They found improved overall mortality only in the studies with interventions initiated before the onset of organ failure and mortality of >20% in the control group. et al (17). but a suggestion of benefit if the goals are achieved preoperatively. More recently. 40% of the control patients achieved these parameters spontaneously compared to 70% of the protocol patients. Additional Invasive Hemodynamic Monitoring Parameters Occult cardiac dysfunction may be an issue in many trauma patients. after fluid resuscitation. increasing O2 delivery with dopexamine in high-risk surgical patients improved mortality and rate of complications. et al (20). compared to 30% of those who did not. Scalea. instituted a protocol of early invasive hemodynamic monitoring of high-risk geriatric blunt trauma victims. et al (23). The greatest benefit seems to be in the sickest groups of patients. using a bedside computerized decision support tool suggested that there was no difference in outcome between an O2 delivery goal of 600 ml/min/m2 or 500 ml/min/m2. There were no differences in mortality or MODS. In contrast. found that. et al (18). inotropes. Boyd. In this study. Second. Gattinoni. A recent study by McKinley. They grouped the studies by the timing of intervention (before or after the onset of organ dysfunction) and mortality in the control group. these studies can not be totally blinded. reviewed the evidence for supraphysiologic goals for O2 delivery in surgical patients and found no overall benefit. or normal SvO2 (>70%). et al (19). They found that monitoring identified occult shock early and may have helped to prevent MODS and death. First. In a heterogeneous group of medical and surgical critically-ill patients. resuscitated patients to a normal CI (2. patients in the control arms often attain the same physiologic endpoints as those in the treatment arm. None of the patients who attained these parameters died.5 L/min/m2). it seems that optimization of hemodynamic variables should be initiated as early as possible during resuscitation. In a general population of critically ill patients.
The difference in survival did not reach statistical significance. et al (32). CI. In the face of potentially variable ventricular compliance and intrathoracic pressure. or contusion) and intrathoracic pressure (mechanical ventilation).e. are needed. Arterial base deficit Inadequate tissue O2 delivery leads to anaerobic metabolism. In a separate study. The group at Bowman Gray School of Medicine has explored the use of a variety of parameters that can be measured or calculated using a pulmonary artery catheter. demonstrated that CI correlates better with RVEDVI than PCWP up to very high levels of positive end-expiratory pressure. The degree of anaerobiosis is proportional to the depth and severity of hemorrhagic shock. Kincaid. as determined by a lower ratio of afterload (aortic input impedance) to contractility (ventricular end-systolic elastance). Cheatham. suggested that the optimal RVEDVI for each patient could be calculated based on measurements of ventricular compliance. et al (26). A recent study by Eachempati. This should be reflected in the base deficit and lactate level. they found that survivors also had better ventriculararterial coupling. This group of patients (n=20) was compared to a group of patients from a previous prospective study (n=39). This value can be determined using a right ventricular ejection fraction/oximetry volumetric catheter. LVSWI and LVP. these investigators (30) found that improved ventricular-arterial coupling during resuscitation was associated with improved myocardial efficiency (ratio of stroke work to total myocardial energy output as measured via the pressure-volume loop) and decreased base deficit.0144) and left ventricular power output (LVP=cardiac index x [mean arterial pressure-central venous pressure]). They then prospectively resuscitated patients attempting to achieve the survivors’ level of LVP (>320 mm Hg x L/min/m2) (29). Patients who did not normalize lactate or reach their hemodynamic goals by 24 hours were at high risk of dying. Central venous and pulmonary capillary wedge pressures are useful. with the purely flow-derived hemodynamic and O2 transport variables as predictors of outcome in critically-ill trauma patients. and O2 consumption index did not correlate with pHi. Recognizing that fluid resuscitation is the primary treatment for trauma patients in hemorrhagic shock. The patients resuscitated to the LVP goal normalized their base deficit sooner and had a lower risk of developing organ system failure. ischemia.Endpoints of Resuscitation Page 6 and O2 consumption was no longer flow dependent. Patients with splanchnic hypoperfusion as defined by low gastric mucosal pHi had a high risk of developing MODS and death. O2 delivery index. optimized preload. i. examined hemodynamic parameters in patients with normal vs low gastric pH after severe trauma. suggests that serum © 2003 Eastern Association for the surgery of Trauma . et al (28). Arterial pH is not as useful as it will be “defended” by the body’s compensatory mechanisms (31). Chang. but have limitations in critically ill patients due to changes in ventricular compliance (edema. The only variables that significantly correlated with lactate clearance and survival were heart rate. indicators of adequate volume status. measurement of RVEDVI may more accurately reflect left ventricular preload than CVP or PCWP. et al (24). D.. Using the ventricular pressure-volume relationships. which encompass blood pressure and flow. compared the hemodynamic variables left ventricular stroke work index (LVSWI=stroke index x mean arterial pressure x 0. Normalized pHi and high RVEDVI were strongly associated with better outcomes. Chang. et al (27). These patients also had lower RVEDVI than those with normal pHi. Recently. PCWP. This same group (25) examined 79 consecutive critically ill trauma patients.
et al (34). found that the initial base deficit was significantly higher in patients who developed acute lung injury compared to those who did not. To determine preoperative factors that could predict outcome in the most severely injured patients. coagulopathy. Elevated base deficit is not only predictive of mortality. which may be more readily available than arterial blood gases. but of complications. added that base deficit correlated with mortality and enhanced the predictive value of the TRISS methodology (35). The importance of a normal base deficit may vary with different patient populations. Only base deficit remained predictive by multivariate analysis. Davis. Eberhard. found that base deficit. correlate very well with base deficit values. Base deficit changes over time may add to the utility of these levels. Using base deficit. Rutherford. Davis.5oC and base deficit >5 mmol/L) were strong predictors of death. further suggested a good correlation between base deficit and blood product requirements. et al (42). or severe (base deficit >14 mmol/L). and a combination (temperature <35.Endpoints of Resuscitation Page 7 bicarbonate concentrations. Siegel. length of stay. Eachempati. blood pressure on admission. moderate (base deficit 6-14 mmol/L). high transfusion requirements. et al (33). et al (38). found that base deficit and initial 24 hour blood transfusion requirements were independently predictive of mortality. retrospectively examined 40 patients with multivisceral trauma (ISS >35) who required urgent operations for hemorrhage. found that a base deficit of >6 mmol/L is a marker of severe injury in all patients. and MODS. retrospectively found that higher base deficit was associated with lower blood pressure on admission and greater fluid requirements. Using a multivariate analysis. et al (37). et al (44). Sauaia. They stratified patients’ level of illness as mild (base deficit 2-5 mmol/L). Two-thirds of patients with an increasing base deficit had ongoing blood loss. as evidenced by lower O2 consumption and O2 utilization coefficient. those that had persistently high base deficit had greater risk of MODS and death. Krishna. similarly found that an increase in base deficit between arrival at the hospital and admission to the intensive care unit identified trauma patients with hemodynamic instability. These patients also demonstrated impaired O2 utilization. The combination of Glasgow Coma Scale and base deficit produced the best predictive model. and ISS. particularly the acute respiratory distress syndrome (ARDS). et al (36). Age and injury severity score (ISS) were also important variables. Lactate levels and ISSs were not. although they did not find base deficit to independently correlate with mortality.5% accuracy. In victims of penetrating trauma. Davis. et al (43). et al (45). further found that. found that changes in base deficit over time were more predictive of survival than pH levels. Rixen. found that worst base deficit in the first 24 hours. metabolic and coagulation abnormalities. and transfusion requirements were predictive of the development of multiple organ failure. renal failure. et al (41). Falcone. et al (31). Kincaid. et al (39). Davis. and estimated blood loss were predictive of mortality by univariate analysis. lactate. Because of its availability and rapidity. they could predict outcome with 92. but a normal base deficit was associated with an ISS of >16 in patients older than 55 years more often than in younger patients. et al (40). found that admission base deficit correlated with need for blood transfusion (72% if base deficit >6 mmol/L vs 18% if base deficit <6 mmol/L). among trauma patients who normalized their lactate levels. severe metabolic acidosis (base deficit >12 mmol/L). Rixen and Siegel (46) found that both high lactate and base deficit during the first © 2003 Eastern Association for the surgery of Trauma . such as the need for blood transfusions and organ failure. the base deficit has been extensively studied. core temperature. Severe hypothermia (<33oC). and an increased risk of death. ARDS.
those that did not normalize by 48 hours had an 86% mortality rate. Arterial lactate Vincent. All patients who had normalized lactate levels at 24 hours survived. They found that the time needed to normalize serum lactate levels was an important prognostic factor for survival. They found that both base deficit and lactate levels correlated with transfusion requirements. such as fluid resuscitation. showed that not only were initial lactate levels important. et al (58). et al (32). There is little role for sodium bicarbonate in the treatment of hemorrhagic shock. et al (48). and revised trauma score. Dunne. ISS. correlated with the development of MODS after trauma.1 is concerning in non-intoxicated patients. Base deficit >8 mmol/L corresponded with a 25% mortality risk. Admission base deficit correlated with systolic blood pressure. found no difference in length of stay regardless of alcohol level. have shown that serum bicarbonate levels. found that. et al (53).1 mmol/L should be concerning in intoxicated patients. Eachempati. but the response of the lactate level to an intervention. et al (47). although 21% of patients had ingested alcohol and 7% had used other drugs. development of a hyperchloremic metabolic acidosis from resuscitation with normal saline or lactated Ringer’s solution can increase base deficit for the same degree of injury severity (54). prospectively studied 40 patients who required operations for truncal injuries to see what factors would best determine which patients were at the greatest risk of developing hemodynamic instability. © 2003 Eastern Association for the surgery of Trauma . would add predictive value in patients with noncardiogenic circulatory shock. Dunham. particularly lactic acidosis. found that base deficit can also reflect injury severity and risk of mortality in pediatric patients. et al (50) Base deficit levels may be confounded by a number of factors. Manikas. Bannon. A base deficit of >6 mmol/L was still predictive of a significant injury and need for blood transfusion. correlate well with base deficits. et al (56). Abramson. In addition. et al (55). et al (52). et al (57). suggesting that inflammatory processes are involved in the relationship between severity of post-traumatic shock and later development of MODS and death. admission lactate and base deficit remained as significant independent predictors of outcome. found a similar trend in post-operative surgical patients admitted to the ICU. E. Acidosis secondary to hyperchloremia is associated with a lower mortality than that from other causes. whereas a base deficit of 1. et al (51). Botha. Kincaid. et al (49). further found that initial and peak lactate levels. as well as the duration of hyperlactatemia. studied patients who had severe trauma and were resuscitated to supranormal values of O2 transport (8). Almost all studies of base deficit have focused on adults. Alcohol intoxication can worsen base deficit for similar levels of injury severity and hemodynamics after trauma. Davis. found that base deficit values correlated with neutrophil CD11b expression. Administration of sodium bicarbonate will at least transiently improve base deficit and bicarbonate levels and confound their use as endpoints for resuscitation.Endpoints of Resuscitation Page 8 24 hours of admission were associated with high interleukin-6 levels and ARDS. those patients who normalized their levels between 24 and 48 hours had a 25% mortality rate.179 patients). which may be more readily available from some labs. whereas mixed venous O2 saturation did not. This was corroborated by Randolph. McNelis. Using an even larger database (15. suggest that a base deficit of >4. especially within the first 4 days of admission.
G. Gastric tonometry is based on the finding that tissue ischemia leads to an increase in tissue PCO2 and subsequent decrease in tissue pH.32 had a mortality of 37% whereas those with higher pHi all survived. but nonsurvivors had greater O2 consumption. lower arterial-end tidal CO2 differences. Correlations between these variables were poor. Boyd. and gut). found that markers of metabolic acidosis (base deficit and bicarbonate levels) correlated well with pHi. and lactate levels. as measured by end-tidal CO2.65 had a 77% sensitivity and a 96% specificity of predicting pHi of <7. et al (65). Gastric tonometry The stomach has been called the canary of the body (61). et al (63). Continuous CO2 electrodes are also available. Intramucosal pH (pHi) can be calculated based on the HendersonHasselbach equation. In theory. F. the PCO2 in gastric secretions rapidly equalizes that in the gastric mucosa. detection of subclinical ischemia to these organs would allow identification of patients who require additional resuscitation despite seemingly normalized vital signs.35 or 0. and O2 uptake were not different between survivors and nonsurvivors.1 units below the previous value. et al (59). suggested that pHi was a better predictor of mortality in a general ICU population than arterial pH.Endpoints of Resuscitation Page 9 In theory. et al (66). et al (67).32. Gys. In contrast. et al (64). All patients who died had pHi values <7. and decreased alveolar dead space ratio (estimated as the arterial-end tidal CO2 difference/arterial PCO2) compared to nonsurvivors. found that lactate levels were higher in nonsurvivors than in survivors. Interestingly. and lower pHi. blood flow to the most vulnerable organs (brain and heart) is maintained at the expense of other organs (skin. The balloon is filled with saline and CO2 is allowed to diffuse into the balloon for a specific period of time. O2 delivery. This can then lead to an increase in the difference between arterial and alveolar CO2. In 22 medical and surgical ICU patients. randomized critically ill patients to standard treatment vs a protocol that called for increasing O2 transport or decreasing O2 demand if the pHi decreased below 7. For gastric tonometry to be accurate. base deficit. The total number of patients was small and the lactate levels were used to guide resuscitative efforts. et al (60). Maynard. the severity of metabolic acidosis secondary to tissue hypoperfusion should be similarly reflected in lactate levels and anion gap or base deficit. End-tidal Carbon Dioxide Levels Reduced cardiac output and/or abnormal distribution of pulmonary blood flow can lead to increased pulmonary dead space. it is necessary to withhold gastric feedings and suppress gastric acid secretion. muscle.32. Survivors and nonsurvivors had similar O2 delivery. Similar correlations were not true for anion gap or base deficit. CI. Patients with pHi <7. A semi-permeable balloon is placed into the stomach attached to a special nasogastric tube. showed that lower pHi correlated with development of MODS and increased mortality in critically ill patients. Mikulaschek. O2 extraction ratio. In 52 critically ill trauma patients. mixed venous pH. compared pHi to O2 transport parameters in survivors and nonsurvivors. In a separate study. and mixed venous PO2. kidneys. Finding base deficit of >4. and lactate levels. found that pHi correlated with sepsis score. As systemic perfusion decreases. Gutierrez. prospectively studied 106 trauma patients who required operations. Doglio. The PCO2 in the saline is then measured. Gutierrez. et al (62). Survivors had higher end-tidal CO2. Because CO2 diffuses so readily across tissues and fluids. Survival was similar between groups © 2003 Eastern Association for the surgery of Trauma . In a group of 59 surgical ICU patients. particularly if the low pHi persisted for >12 hours. Tyburski.
The ability to predict MODS and death was maximized with pHi <7. prospectively studied 15 blunt trauma patients who required operations. blood glucose <12 mmol/L. Imai. lactate. They found no correlation between initial pHi and ISS. resuscitated patients in a general ICU using a standardized protocol to maintain mean arterial pressure >70 mmHg. et al (70). and death than achieving the O2 transport goals. hemoglobin >8 g/dl. but the protocol improved survival in those patients with initially normal pHi. et al (26). In the postresuscitation period. complications. MODS. systolic blood pressure >90 mmHg. All 7 with normal pHi had uncomplicated recoveries. et al (68). et al (72. Wall. et al (75). Technologic limitations of measuring gastrointestinal PCO2 should be kept in mind. An airflow tonometer in which the balloon is automatically filled with air and the air is removed after a set period of time is also now approved by the Food and Drug Administration. © 2003 Eastern Association for the surgery of Trauma . Three of these 8 developed complications and 2 died. Time taken to optimize pHi or O2 transport variables was similar. or length of stay. if necessary. similarly found that pHi <7. Roumen. The original. or acute physiologic and chronic health evaluation (APACHE) II scores. et al (74). urine output >0. delay in achieving pHi goals was more predictive of organ system failure. Treatment goals were achieved in almost all patients.73). Fiberoptic systems using a spectrophotometric method for continuous monitoring are being developed. using a cohort of 114 trauma patients. In contrast. Looking at both groups.Endpoints of Resuscitation Page 10 if the initial pHi was low. The CO2 gap is a better indicator of gut “dysoxia” than pHi. manual technique using a semi-permeable balloon is cumbersome.32) initially or subsequently. but simultaneous samples in vivo during hemorrhagic shock and resuscitation in dogs differed significantly. and correction of uncompensated respiratory acidosis. which is a calculated variable that may be altered by arterial bicarbonate levels (71). Threshold values for pHi and for the gastric mucosal-arterial CO2 gap were explored by Miller. Using pHi as an endpoint (>7. et al (69). The fiberoptic values were greater than the airflow values. the only factor that was different between patients who developed MODS and those who did not was pHi. Chang. Gomersall. There were no differences between groups in mortality.3) for resuscitation was compared to supranormal O2 transport variables (O2 delivery index of 600 mL/min/m2 and a O2 consumption index of >150 mL/min/m2) in a prospective. The resuscitation protocol included volume loading with crystalloid and blood followed. The only parameter that remained different between groups was pHi.35. randomized study of 57 trauma patients by Ivatury. Both methods could theoretically change the environment within the stomach by either adding O2 or removing CO2. The authors recommend using the fiberoptic approach since it does not interfere with the local gas environment. but at 24 hours.32 was a good predictor of MODS and mortality. Eight had low pHi (<7. All patients who developed MODS had pHi <7. arterial O2 saturation >94%.25 and gap of >18 mm Hg.1. shock. Patients were then randomized to continued standard therapy or additional fluid resuscitation and/or dobutamine to achieve pHi >7. In trauma patients. found that the airflow and fiberoptic devices correlated well with each other in vitro. Based deficit and mixed venous O2 saturation were also independently associated with mortality. The gap between gastric mucosal and arterial CO2 was similarly predictive. with inotropic support using dobutamine. recently reported on the utility of a different type of CO2 electrode that could continuously measure PCO2 in the stomach. persistently low or decreasing pHi was an early signal of complications.5 ml/kg/hr.
higher revised trauma scores. Their hypothesis was that patients who were adequately resuscitated would respond with an increase in tissue PO2 since flowdependent O2 consumption would not be present. showed that gastric tissue O2 saturation. Near infrared spectroscopy (NIRS) Measurement of skeletal muscle oxyhemoglobin levels by NIRS offers a non-invasive method for monitoring adequacy of resuscitation in terms of normalizing tissue oxygenation. In victims of penetrating trauma. et al (82). demonstrated that sublingual PCO2 correlates with lactate levels. took this concept one step further by measuring deltoid muscle PO2 via a needle-mounted probe before and after an O2 challenge. et al (84). presence of shock. et al (79). Weil. higher transcutaneous PCO2 values. in 18 trauma patients. Drucker. Studies in humans are in progress. Waxman. Jonsson. Tissue PO2 would not increase if flow dependent O2 consumption is present and cells consume all additional O2. Tatevossian. decreased rapidly. Cohn. In human volunteers donating 470 ml of whole blood. measured transcutaneous PO2 and PCO2 in critically ill trauma patients. correlating with superior mesenteric artery (SMA) blood flow. and shorter hospital stays than nonresponders (n=9). Strong correlations were found between both PCO2 values and mesenteric blood flow. compared duodenal and sublingual PCO2 to mesenteric blood flow during hemorrhagic shock in pigs. Tissue oxygen and carbon dioxide electrodes Measurements of transcutaneous O2 and CO2 levels may also be predictive of death in critically ill patients based on the same principles of gastric tonometry. I. showed that sublingual PCO2 was elevated in patients with ongoing bleeding.Endpoints of Resuscitation Page 11 An intriguing new approach to determine regional hypercarbia during shock is the use of sublingual PCO2 monitoring. found that cerebral cortex and calf muscle O2 saturation measured by NIRS decreased in proportion to © 2003 Eastern Association for the surgery of Trauma . Finally. et al (78). Patients who died had lower transcutaneous PO2 values. All patients died who had transcutaneous PCO2 values >60 torr for >30 min. measured continuously with a prototype side-illuminating NIRS nasogastric probe. and survival in a small group of acutely ill patients. et al (85). The correlation of SMA flow with tonometric CO2 in the jejunum was not as good. Responders (n=6) during acute trauma resuscitations had lower ISS. although not always to baseline. Göte. They first demonstrated that this probe worked as well as a standard Clark electrode and then demonstrated in animals that the subcutaneous PO2 decreased rapidly during hemorrhagic shock and increased with resuscitation. et al (81). They found that subcutaneous PO2 values were higher in the survivors. Torella. et al (83). utilized an optical sensor (optode) placed into subcutaneous tissues to examine peripheral perfusion. In pigs undergoing hemorrhagic shock. et al (77). measured subcutaneous PO2 in 10 patients undergoing emergency intestinal surgical procedures using a tonometer implanted in the abdominal wall. they found that many still had low subcutaneous PO2 levels despite adequate resuscitation by standard clinical criteria. and longer periods of time with transcutaneous PCO2 values >60 torr. suggesting ongoing peripheral vasoconstriction. Povoas. had previously used a similar technique to show that many patients who underwent abdominal surgical procedures were suboptimally perfused. In 14 trauma patients already in the intensive care unit. et al (80). response to the O2 challenge test correlated very well with evidence of flow dependency via pulmonary artery catheterization. Baron. H. et al (76).
and urine output are not adequate to guarantee survival without organ system dysfunction. Many can be useful for predicting risk of organ failure and death. They found that both PO2 and PCO2 changed rapidly during shock and resuscitation. as well as the adequacy of resuscitation. found that 8 of 9 trauma patients who developed multiple organ failure had decoupling of these values. McKinley. acid-base status. examined the ability of 2 intensivists to diagnose hypoperfusion by physical examination of patients’ extremities. Sims. tissue oxyhemoglobin levels. Cairns. and higher lactate levels. and SvO2. At present. found that placement of a fiberoptic multiparameter sensor into skeletal muscle could also be useful for monitoring the severity of hemorrhagic shock in pigs. Normally. Studies comparing use of these parameters as endpoints for resuscitation protocols. Small bowel pH changed most rapidly during shock and resuscitation. V. They found that StO2 correlated with systemic O2 delivery.88). base deficit. may provide even better prediction of outcomes and better endpoints for resuscitation (89. and pH. and regional measures of tissue O2 and CO2 levels have been studied. et al (92). PCO2. et al (91). Numerous parameters including hemodynamic profiles.90). PCO2. Physical Examination Despite all the interest in laboratory values. have failed to show clear benefit in terms of patient outcomes. Puyana. The pH correlated best with blood loss.Endpoints of Resuscitation Page 12 blood loss. This correlation was better than that found with gastric mucosal PCO2 and PCO2 gap (difference between gastric PCO2 and arterial PCO2). found in pigs that intra-abdominal organs respond differently. heart rate. whereas only 2 of 16 patients who did not develop multiple organ failure had decoupling. pH. bicarbonate levels. it seems prudent to use one of these endpoints rather than relying on standard clinical parameters. In addition to monitoring tissue oxygenation. During hemorrhagic shock. whereas pH decreased. PCO2. J. and PCO2 gap were not as sensitive. Compared with patients with warm extremities. however. as well as data from invasive and noninvasive monitoring devices. are tightly coupled to cytochrome a. The oxygenation index ([oxygenated hemoglobin]-[deoxygenated hemoglobin]) also decreased proportionally. but did not return to baseline. particularly the liver. and pH of solid organs. SUMMARY During resuscitation from traumatic hemorrhagic shock. normalization of standard clinical parameters such as blood pressure. Persistently low pH and hypercarbia resulted from ongoing bleeding and incomplete resuscitation despite normalized blood pressure.a3 redox. studied O2 saturation of hemoglobin in tissue (StO2 = HbO2/[HbO2+Hb]) during resuscitation in trauma patients. et al (87. one should not discount the value of a good physical examination. The intensivists described the patients’ extremities as either warm or cool. those with cool extremities had lower CI. et al (93). © 2003 Eastern Association for the surgery of Trauma . reflecting mitochondrial O2 consumption. Simultaneous measurements of tissue PO2. Kaplan. et al (86). Gastric mucosal pH. reflecting local O2 supply. used to determine the adequacy of resuscitation. and lactate. NIRS can provide information regarding mitochondrial function. gastric tonometry. NIRS technology allows the simultaneous measurement of tissue PO2.
bias (by investigators and device manufacturers). In addition. but these are difficult to control because of lack of blinding. The next critical. unanswered question. Well-controlled clinical trials comparing parameters as endpoints for resuscitation are needed. How do we know that the patient is adequately volume loaded? Once volume loaded. may be unrealistic.e. Answering these questions will require systematic approaches to the problem in the context of coordinated research efforts. which inotropes and/or vasopressors are best for achieving the chosen endpoint? What should the optimal hematocrit be early in resuscitation? Another set of important unanswered questions relate to subsets of trauma patients. and cheap. once “optimal” endpoint(s) are determined. © 2003 Eastern Association for the surgery of Trauma . is how to achieve them. For example.Endpoints of Resuscitation Page 13 VI. a single endpoint that works for all trauma patients. beta-blockade and heart rate control may be valuable and use of inotropes that increase myocardial work along with massive volume loading may be detrimental. Multi-center studies should be instituted to achieve the large numbers of patients that will be needed to complete the studies in a timely fashion and to assure utility of the technique across a variety of patient populations and physician practices. non-invasive. The search for the “holy grail”. given that use of at least one parameter has become practically standard. FUTURE INVESTIGATION The ideal parameter to use as an endpoint for resuscitation would be reliable. acid-base parameters may not work in patients with acid-base disturbances that are acute (alcohol intoxication) or chronic (renal failure). comparing to a standard of care may become more difficult. perhaps even unethical. easy to use. i. safe. and need for strict control of resuscitation protocols.. For older patients.
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15:106-111. 93. Sims C. Cingo N. 92. Seigne P. 89. Crit Care Med 2000. J Trauma 2001. Soller BR.29:1438-1444. Cingo NA. Cairns CB.50:620-628. Soller BR.51:1137-1146. 91. Santora TA.42:532-6.28:2557-2562. Shock 2001. © 2003 Eastern Association for the surgery of Trauma . Trooskin SZ: Start with a subjective assessment of skin temperature to identity hypoperfusion in intensive care unit patients. Moore FA. Puyana JC. et al: Simultaneous measurement of hepatic tissue pH. 90. J Trauma 2001. McPartland K. Soller BR. Crit Care Med 2001. Heard SO. et al: Evidence for early supply independent mitochondrial dysfunction in patients developing multiple organ failure after trauma. Haenel JB. Kaplan LJ. Menconi M. venous oxygen saturation and hemoglobin by near infrared spectroscopy. Parikh B. et al: Application of fiberoptic sensors for the study of hepatic dysoxia in swine hemorrhagic shock. Heard SO: Directly measured tissue pH is an earlier indicator of splanchnic acidosis than tonometric parameters during hemorrhagic shock in swine.Endpoints of Resuscitation Page 19 88. Puyana JC. J Trauma 1997. et al: Skeletal muscle acidosis correlates with the severity of blood volume loss during shock and resuscitation.
04 Bishop. MA 9 patients achieved goals with volume alone. MH CI. 1994 Elevation of systemic oxygen delivery in the treatment of critically ill patients. WC 1973 Physiologic patterns in surviving and nonsurviving shock patients: Use of sequential cardiorespiratory variables in defining criteria for therapeutic goals and early warning of death. I 1995 Prospective. Ann Surg 232:409-18. and reduced oxygen transport. and ICUand vent days. and Oxygen Consumption as Resuscitation Endpoints in Severe Trauma. N Engl J Med 330:1717-22. Death rate was zero among patients who achieved optimal values compare to 30% among those who didn't. © 2003 Eastern Association for the surgery of Trauma . organ failure. high pulmonary vascular resistance. Randomized Trial of Survivor Values of Cardiac Index. organ dysfunction. RM I Velmahos. Comment: age younger then 40 years old was the only independent factor of the ability to reach optimal values Cardiorespiratory patterns of non survivors surgical/trauma patients were characterized by reduced cardiac output. 50 tx. J Trauma 41:32-40. They proposed that these should be used as defined criteria for therapeutic goals.2% P=0. Chest 94:1176-86.015) and halving of the mean number of complications per patient in the protocol group (P=0. JAMA 270:2699-2707. Boyd.First author Year Title Class of Conclusions evidence Oxygen Delivery Shoemaker. II The incidence of organ failure and death is similar for patients resuscitated based in O2 transport parameters vs conventional parameters. Given adequate vlume resuscitation O2 based parameters are more useful as predictors of outcome than as endpoints of resuscitation. WC 1988 Prospective trial of supranormal values of I Resuscitating to preordained oxygen transport variables may survivors and therapeutic goals in high risk reduce morbidity and mortality in high-risk surgical patients. sepsis. In house mortality was LOWER in the control group than the treatment group (34% vs 54% P=0. surgical patients. Oxygen Delivery. VO2I therapeutic goals achieved within the first 24 hrs were associated with decreased mortality. No difference in mortality. 1996 The Use of Oxygen Consumption and Delivery as Endpoints for Resuscitation in Critically III Patients. 50 control. DO2I.7% vs 22. 2. J Trauma 38:780-787. Arch Surg 106:630-636. 2000 Endpoints of resuscitation of critically injured patients: normal or supranormal? A prospective randomized trial. 2 Conclusions and one comment: 1. O 1993 A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgery. GC I Shoemaker. Inhouse mortality for the nine was zero.008) Hayes. I I Results: A 75% reduction in mortality (5. Durham. LOS between the two groups.
Am J Surg 146:43-50. © 2003 Eastern Association for the surgery of Trauma . J Trauma 53:825-832 II II II II II The maximum cumulative oxygen debt is significantly less in patients without organ failure than that of nonsurvivors and survivors with organ failure. Normal versus supranormal oxygen delivery goals in shock resuscitation: the response is the same. associated with improved outcome. although less fluid was needed in the lower oxygen delivery cohort. survival with early invasive monitoring. The outcomes were the same. Supranormal DO2 vs normal. and will help prevent MOF and improve survival. Oxygen consumption is not different between the 3 groups intraoperatively. ?randomized Moore. limits hypoperfusion. Crit Care Med 24:517-524. The patients had elevated lactate levels and also predicted MOF Bishop. Additional Invasive Hemodynamic Monitoring Parameters Scalea. FA 1992 Fifteen of these patients (38%) did not meet this VO2 goal at 12 hours. No change in mortality. Crit Care Med 16:1117-1120. L 1995 A trial of goal-oriented hemodynamic therapy in I Maximization of CI > 4. WC 1983 Use of physiologic monitoring to predict parameters retrospectively derived from a survivor group were outcome and to assist clinical decisions in the critically ill postoperative patients. McKinley. WC 1988 Tissue oxygen debt as a determinant of lethal and non-lethal postoperative organ failure. SvO2 Collaborative Group. Mixed Venous Oxygen Saturation Gattinoni. and outcome in severely traumatized patients. A 1992 Prospective trial of supranormal values as a goal of resuscitation in severe trauma. MH 1993 Severely traumatized patients may improve survival if 'supranormal values of DO2 and VO2 are achieved by 24 hours. III Goals of resusc. Incommensurate oxygen consumption in response to maximal oxygen availability predicts postinjury multisystem organ failure. Maximizing oxygen delivery in critically ill patients: A methodologic appraisal of the evidence. DK 1996 Mortality is unchanged when DO2 and VO2 are driven to "supraphysiologic" levels in critically ill patients. less vent days. J Trauma 30:129-136.5 or SvO2 > 70% did not reduce critically ill patients. Fewer organ failures. N Engl J Med 333:1025-32. Relationship between supranormal circulatory values. to achieve median values of cardio-pulmonary Shoemaker.Endpoints of Resuscitation Page 21 Shoemaker. BA 2002 Non-randomized study of 2 oxygen delivery goals (600 vs 500 ml/min/m2) implemented with a computer-based protocol. II Fleming. Heyland. morbidity or mortality in critically ill patients. shorter ICU LOS. Crit Care Med 21:56-63. J Trauma 33:58-67. TM 1990 Geriatric blunt multiple trauma: improved II Emergent invasive monitoring identifies occult shock early. Arch Surg 127:1175-1181. time delays.
Early invasive monitoring is necessary to define the adequacy of the cardiac response and individually taylor therapy. MC Chang. J Trauma 50:665-669 2000 2002 2001 II Cheatham. B II 1994 Hemodynamic responses to shock in young trauma patients: Need for invasive monitoring. II II Young trauma patients have substantial but clinically occult myocardial depression after shock and most of these patients require inotropes to optimize and clear circulating lactate. blood. and their relationship during resuscitation in trauma patients. stroke work. power. and vetricular-arterial coupling. Prospective study of critically-ill trauma patients who needed a pulmonary artery catheter. These values may be used in conjunction with oxygen transport variables to manage these patients. Patients who do not optimize and clear their lactate within 24 hours may not survive. J Trauma 37:488-94. Maintaining survivors' values of left ventricular power output during shock resuscitation: a prospective pilot study. RVEDVI better predicts volume state and response to volume infusion than PAOP pressure Chang. J Trauma 49:26-33. with better outcome. Improving ventricular-arterial coupling during resuscitation from shock: Effects on cardiovascular function and systemic perfusion. was associated with improved BD clearance and lower rates of organ disfunction Chang II Kincaid. Keeping the RVEDVI > 100 may improve outcome Prospective study of critically-ill trauma patients. 1997 Cardiac preload. EH III Prospective study of critically-ill trauma patients. Resuscitation with fluids. J Trauma 45:470-478 1998 Right ventricular end-diastolic volume index as a predictor of preload status in patients on positive end-expiratory pressure.Endpoints of Resuscitation Page 22 Abou-Khalil. Ventricular compliance curves were constructed during volume loading using RVEDVI measurements. Crit Care Med 22:633-639. Crit Care Med 26:1801-1806. Chang. levt ventricular power. and the pressure-volume diagram. Chang. and inotropes based on left ventricular power output ventricular-arterial coupling led to rapid base deficit clearance and improved myocardial efficiency. J Trauma 53:679-685 Determining optimal cardiac preload during resuscitation using measurements of ventricular compliance. blood. Low pHi correlates with morbidity and mortality in surgical patients. MC 1998 Redefining cardiovascular performance during resuscitation: Ventricular stroke work. MC 1994 Gastric tonometry supplements information provided by systemic indicators of oxygen transport. Survivors had lower heart rates. and inotropes with a goal of rapid normalization of lactate level. Conclusions: Supranormal levels of preload during shock resuscitation are ass. ML II Patients in the normal group had a statistically sig. Also the patients in the normal group maintained a higher RVEDI throught the res. lower incidence multpile organ failure and death. J Trauma 42:577-82. © 2003 Eastern Association for the surgery of Trauma . Resuscitation with fluids. MC II Maintaining LVP > 320 during resusc. splanchnic perfusion.
A Arterial Base Deficit 1992 Base deficit stratifies mortality and determines II Based deficit is an expedient and sensitive measure of both the therapy. MP BD and LA are better than central venous oxygen saturation (ScvO2)as indicators of blood loss as measured by peritoneal shed blood volume. Hyperchloremic metabolc acidosis can be induced by LR resuscitation and may lead to inappropriate clinical interventions due to the incorrec presumption of ongoing tissue hypoxia. at risk for increasing transfusion requirements and ICU + hosp LOS. Admission base deficit predicts transfusion requirements and risk of complications. SA 2001 Hyperchloremic metabolic acidosis is a common cause of metabolic acidosis in the SICU and is associated with lower mortality than metabolic acidosis from other causes. Am Surg 61:738-45. preop hypotension and transfusion requirement Davis. and mortality. II Randolph 2002 Resuscitation in the pediatric trauma population: admission base deficit remains an important prognostic indicator. 1994 1995 Early predictors of postinjury multiple organ failure.Endpoints of Resuscitation Page 23 Rutherford. Crit Care Med 28:125-31. J Trauma 33:417-23. J Trauma 41:769-74. EJ Sauaia. ISS + >6u RBC 1st 12 hrs post injury were early predictors of MOF. Base Deficit Does not Predict Mortality When it is Secondary to Hyperchloremic Acidosis. Age. Base deficit is superior to pH in evaluating clearance of acidosis after traumatic shock. arterial base deficit. Base deficit after major trauma directly relates to neutrophil CD11b expression: a proposed mechanism of shock-induced organ. and lactate concentration in trauma patients. LW 2000 Base deficit reveals differences in metabolic acidosis between survivors and non-survivors not identified by pH determination. AJ 1997 The degree of metabolic acidosis after trauma correlates with CD11b receptor expression on circulating neutrophils Davis. The ED base deficit(BD) and the total crystalloid volume in 24h predict the development of ALI while total number of transfusions does not Brill. J Trauma 53:838-842 Retrospective study of pediatric trauma patients admitted to an intensive care unit. Admission BD is associated with shock. Intens Care Med 23:504-9. degree and duration of hypoperfusion. Base deficit is a better mark of acidosis clearance after shock. Initial severity of metabolic acidosis predicts the development of acute lung injury in severely traumatized patients. BD and lactate were also helpful. JW 1998 Eberhard. Shock II II II II II II II Bannon. Central venous oxygen saturation. Failure to clear BD was associated with 100% mortality. It is a useful clinical tool and enhances predictive ability of revised trauma score and TRISS. J Trauma 44:114-8. Botha. Arch Surg 129:39-45. JW 1996 Admission BD can be used to identify pts. © 2003 Eastern Association for the surgery of Trauma . poor outcome.
G Dunham. World J Surg 17:575-9. but it is particularly ominous in patients 55 years of age and older. Despite this finding BD <-6 remained a significant predictor of major injury regardless of ETOH level.5 AND a Base Deficit of of 5-12 mEq/L The presence of ETOH results in worsening of the base deficit independent of other variables. III Multivariate analysis revealed that only Trauma Score and age are predictive of survival.1 in ETOH positive patients vs. Patients older than 55 years may have significant injuries and mortality risk without manifesting a base deficit out of the normal range A persistently high arterial base deficit is associated with altered O2 utilization and increased MOF and mortality III III Rixen.5 to 33. RE Davis. CM 1998 Elevated arterial base deficit in trauma patients: a marker of impaired oxygen utilization. J Trauma 49:392-403.1 in ETOH negative patients. Maximum oxygen debt (I. J Trauma 45:873-7. 2000 Metabolic correlates of oxygen debt predict posttrauma early acute respiratory distress syndrome and the related cytokine response. JACS 187:384-92. Kincaid. J Trauma 51:332-5. EH Krishna. 2000 Base deficit level indicating major injury is increased with ethanol.e. 1993 Correlation of metabolic acidosis with outcome following injury and its value as a scoring tool. 1998 Physiological predictors of death in exsanguinating trauma patients undergoing conventional trauma surgery. III III 1998 Base deficit in the elderly: a marker of severe injury and death. increased BD and lactate) correlates with early ARDS and death. JW Kincaid. Base deficit is a useful guide to volume replacement in the resuscitation of trauma patients Both extracellular base deficit and the volume of blood transfused in the first 24 hours were significant predictors of mortality. Falcone. D III Strong predictors of death(after multiple logistic regression outcome could be predicted with 92. 2001 Admission base deficit in pediatric trauma: a study using the National Trauma Data Bank. JH 1990 Early physiologic predictors of injury severity and death in blunt multiple trauma. JW Davis. JW III III Siegel.5% accuracy) were: Base deficit >12 mEq/L or T < 33degrees C or a combination of Temp 35. J Trauma 43:507-10. The presence of ETOH results in significantly worse base deficit despite lower ISS and higher Ps in ETOH positive patients.Endpoints of Resuscitation Page 24 Davis. Risk of major injury increases when BD is <-4. III 1988 Base deficit as a guide to volume resuscitation. J Emer Med 18:165-71. BD less than -8 could represent potentially lethal injury and ucompensated shock. 1997 Effect of alcohol on the utility of base deficit in trauma. J Trauma 28:1464-7. EH III In injured children admission base deficit predicts injury severity and predicts mortality.. Arch Surg 125:498-508. <-1. ANZ J Surg 68:826-9. © 2003 Eastern Association for the surgery of Trauma . Base deficit < -6 is a marker of severe injury and significant mortality in all trauma patients. Base deficit is an important predictor of volume of blood needed.
the only factor that Factors associated with mortality in patients with penetrating abdominal vascular trauma.Endpoints of Resuscitation Page 25 Rixen. Lactate and base deficit in trauma: does alcohol III Using a large database of trauma patients. III Retrospective study of postoperative ICU patients. D 2001 Dunne. lower prospective study. unit. Lactate and impair their predictive accuracy? base deficit levels still were predictive of outcome. Correlation of serial blood lactate levels to II 1) initial LA and peak LA were higher in non-survivors 2) initial organ failure and mortality after trauma. Time to clear Prolonged lactate clearance is associated with increased mortality in the surgical intensive care lactate correlated with mortality. Survivors had higher end-tidal CO2 levels. Serum bicarbonate as an endpoint of III Using a large dataset from trauma patients. base excess. the authors found a resuscitation in critically ill patients. II Time to normalize LA is prognostic of survival J Trauma 35:584-589. a lone initial value Crit Care Med 11:449-451. resuscitation. III In patients with penetrating abdominal trauma. Serum Lactate Is Not Predicted by Anion Gap II Lactate. increased mortality. strong correlation between base deficit and serum bicarbonate levels. D Manikis. SR 2002 Eachempati 2003 Vincent. With a Gesellschaft Fur Unfallchirurgie. on admission and blood loss were predictive in univariate analysis. arterial-end tidal CO2 differences. analysis by the trauma registry of the Deutsche This was true for both initial admission and icu admission. JL 1983 Abramson. and decrease alveolar dead space ratio. LA. Surg Inf 4: (in press) Arterial Lactate Levels Serial lactate determinations during circulatory II Serial lactate determinations are more prognostic of survival than shock. Lactate clearances and survival following injury. Am J Surg 182:481-485 End-tidal Carbon Dioxide End-tidal CO2-derived values during emergency II Prospective study of trauma patients who required an urgent trauma surgery correlated with outcome: a operation. © 2003 Eastern Association for the surgery of Trauma . J Trauma 53:188 (abstract). peak LA and duration of LA correlated with organ failures Am J Emerg Med 13:619-622. P 1995 1993 Mikulaschek. Blood pressure J Surg Res 108:222-226. A 1996 McNelis J 2001 Tyburski. the authors found that many patients had ingested alcohol or other drugs. high transfusion requirements. J 2002 Eachempati. independently predicted mortality was base deficit. worsening of BD form hospital to ICU admission there was an Shock 15:83-89.metabolic significance in posttrauma critical illness: An and coagulatory decompensation as well as probability of death. and anion gap do not correlate after or Base Excess after Trauma Resuscitation. JG 2002 III Base deficit is an early indicator to identify patients that will show Base deficit development and its prognostic hemodynamic instability. J Trauma 40:218-224.
Crit Care Med 20:451-7. mixed venous pH and PO2. Resuscitation of critically ill patients based on I Compared standard tx with standard tx plus colloids and the results of gastric tonometry: A prospective. G 1992 Ivatury. Lancet 339:195-9. sublingual CO2 levels detecting hemorrhage in patients with correlated with blood loss.pHi and SvO2 in critically ill patients. RR 1996 Gomersall. persists at 12 h. © 2003 Eastern Association for the surgery of Trauma . MOF. severity of circulatory shock. GR 1991 Maynard.35. Sublingual capnography: a new noninvasive II Prospective. penetrating trauma. resuscitation after major trauma: global oxygen lactate. Assessment of splanchnic oxygenation by II Although a variety of resuscitation endpoints correlated with gastric tonometry in patients with acute surviving critical illness. N 1993 Weil.Endpoints of Resuscitation Page 26 Gutierrez. randomized controlled trial. Normalized later than DO2. only pHi at 24h proved an independent circulatory. JACS 183:145-54. criterion study of acutely-ill patients and normal measurement for diagnosis and quantitation of volunteers. Crit Care Med 28:607-614. and survival. No benefit if initial pHi <7. surgical intensive care patients. Crit Care Med 16:1222-4. RR 1995 Ivatury. observational study. presence of shock. predictor of death by logistic regression JAMA 270:1203-10. No difference in outcome. Gastric mucosal pH as a prognostic index of II Low pHi predicts increased risk of death. Acad Emerg Med (abstract) The prognostic value of gastric intramural pH in III pHi< 7. Worst if mortality in critically ill patients. failure. sepsis. T 1988 Gastric Tonometry Comparison of gastric intramucosal pH with I pHi. lactate all different measures of oxygen transport and consumption between survivors and nonsurvivors. BJ 2002 Gys. of adequacy of resuscitation after trauma. Gastric intramucosal pH as a therapeutic index Improved survival in patients with normal initial pHi. MH 1999 Baron. Crit Care Med 19:1037-40. G 1992 Gutierrez. Gastric mucosal pH and oxygen delivery and I pHi may be an important marker for resuscitation adequacy and an oxygen consumption indices in the assessment early indicator of post-resuscitation complications. of tissue oxygenation in critically ill patients. Final values . Crit Care Med 27:1225-1229. Sublingual PCO2 correlates with lactate level. dobutamine for low pHi. and BD transport indices versus organ. Diagnostic utility of sublingual PCO2 for II In a prospective. worse in nonsurvivors. J Trauma 39:128-34.35 or standard care. A prospective randomized study of end points of I pHi marker of adequate resuscitation. OER. CD 2000 Doglio. I Keep pHi>7.32 may correlate wth short-term mortality.
J Trauma 36:313-316. Threshold values of intramucosal pH and III In trauma patients. Lancet 341:142-146. and tissue perfusion. tonometry for intramural pH. Tissue oximetry as a possible predictor of lethal III Subcutaneous PO2 was measured in 10 patients undergoing complications after emergency intestinal emergency intestinal surgical procedures using a tonometer surgery. Base deficit and bicarbonate levels correlated well with routine blood-gas analysis and from gastric pHi. PR 1998 1994 Jonsson. O2 challenge was considered indicative of flow dependant O2 J Trauma 36:852-856. perfusion in 44 postoperative patients. O 1993 Roumen. RMH Miller. III Gastric pHi may predict morbidity in severely injured patients. Subcutaneous tissue oxygen pressure: a reliable III An optode probe which uses fluorescent techniques accurately index of peripheral perfusion in humans after measures the partial pressure of oxygen in subcutaneous tissues. to be underperfused by the authors definition and was not recognized by clinical criteria. resuscitation. consumption and it was seen in 60 % of patients during acute resuscitation. K 1987 Waxman. Near Infrared Spectroscopy © 2003 Eastern Association for the surgery of Trauma . A negative resuscitation using tissue oxygen monitoring. Subcutaneous Oxygen and Carbon Dioxide Electrodes Assessment of perfusion in postoperative II Subcutaneous tissue oxygen tension was measured as an index of patients using tissue pO2 measurements. W 1996 III Prospective study of patients who required a pulmonary artery Comparison of clinical information gained from catheter. higher in the survivors. H 1990 Drucker.12 of 30 patients were found Br J Surg 74:263-7. Crit Care Med 28:2248-53. the ability to predict death and multiple organ mucosal-arterial CO2 gap during shock failure is maximized when pHi < 7. Gastric tonometry in multiple trauma patients. A method to determine the adequacy of II Monitoring tissue PO2 during an inspired O2 challenge may be a useful test to detrmine the adequacy of resuscitation. implanted in the abdominal wall.Endpoints of Resuscitation Page 27 Boyd. Subcutaneous PO2 values were Surg Res Comm 7:243-249. This measurement correlates with the adequacy of resuscitation J Trauma 40(3 Suppl):S116-22. J Trauma 45:868-72. Transcutaneous oxygen and CO2 as early II Continous PtO2 and PtCO2 monitoring evaluate tissue perfusion warning of tissue hypoxia and hemodynamic and serve as early warning in critically ill patients shock in critically ill emergency patients. injury.25 and gastric mucosal to arterial carbon dioxide gap is greater than 18 mm Hg. RG 2000 Gote. K 1994 Tatevossian.
Hb O2 saturation was monitored non invasively and simultaneously in skeletal muscle and subcutaneous tissue.Endpoints of Resuscitation Page 28 Cairns. Blood loss correlated with regional hemoglobin saturation in the cerebral cortex and left calf muscle. 89% of MOF have abnormal NIR values comapred to 13 % of nonMOF patients Human volunteers undergoing donation of 470 ml blood were studied. F McKinley. BA 2002 Regional tissue oxygenation during hemorrhage: Can near infrared spectroscopy be used to monitor blood loss? Shock 18:440-444. as well as oxygenation index (oxygenated -deoxygenated hemoglobin concentration). III II Patients with severe trauma who developed MOF were found to display abnormal mithocondrial oxidative function. lactate was higher in MOF group. Skeletal muscle O2 tracked systemic O2 delivery. J Trauma 42:532-6. CB 1997 Evidence for early supply independent mitochondrial dysfunction in patients developing multiple organ failure after trauma. Authors sugest that it could be used in combination with BD and lactate to guide resuscitation © 2003 Eastern Association for the surgery of Trauma . At 12 hours of resuscitation MOF and non-MOF patient did not have statiscally different DO2 or VO2. J Trauma 48:637-42. 2000 Tissue hemoglobin O2 saturation during resuscitation of traumatic shock monitored using near infrared spectrometry. II Torella.
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