FAILURE OF SPLANCHNIC RESUSCITATION IN THE ACUTELY INJURED TRAUMA PATIENT CORRELATES WITH MULTIPLE ORGAN SYSTEM FAILURE AND LENGTH OF STAY IN THE ICU

Introduction: The purpose of our study was to evaluate the relationshi p between the state of splanchnic perfusion and morbidity and mortalit y in the hemodynamically unstable trauma patient acutely resuscitated in the ICU. Methods: Gastric intramucosal pH (pHi) was monitored in a blinded fashion in 19 consecutive critically ill trauma patients with evidence of systemic hypoperfusion (arterial pH [pHa] <7.35, base exce ss >2.3 mmol/L, lactic acid >2.3 mEq/L) who received right heart cathe ters to guide resuscitation and subsequent hemodynamic monitoring. Des ign: Prospective randomized consecutive series with retrospective anal ysis of data. Setting: University hospital, surgical ICU. Results: The mean values of APACHE II (acute physiology and chronic health evaluat ion) Injury Severity Score, pHa, arterial base excess, cardiac index, oxygen delivery index, and oxygen consumption index by 24 h were simil ar (Student's t test, p>0.1) between survivors and nonsurvivors and be tween those who developed at most a single (SOF) vs multiple organ sys tem failure (MOSF). Supranormal oxygen delivery and utilization parame ters were evenly distributed among survivors and nonsurvivors and pati ents with SOF and MOSF (chi(2), p>0.5) Ten patients had a pHi <7.32 an d nine patients had a pHi greater than or equal to 7.32 by 24 h. Fifty percent of patients with a pHi <7.32 died, compared with 11% of patie nts with a pH greater than or equal to 7.32 (chi(2), p=0.07). Sixty pe rcent of patients with a pHi <7.32 developed MOSF compared with 11% of patients with a pHi greater than or equal to 7.32 (chi(2), p=0.03) Th e one patient who developed MOSF and died in the pHi greater than or e qual to 7.32 cohort suffered from massive head trauma and had all futi le medical interventions halted. No other patients who achieved a pH g reater than or equal to 7.32 by hour 24 developed MOSF. Survivors with a pHi <7.32 at hour 24 had an increased ICU stay (pHi <7.32=46+/-15 d ays, pHi greater than or equal to 7.32=13+/-9 days; p<0.01). A pHi <7. 32 carried a relative risk of 4.5 for death and 5.4 for the occurrence of MOSF. Conclusion: Attainment of a pHi greater than or equal to 7.3 2 at hour 24 carried a significantly reduced likelihood of MOSF. Being an inference of the state of regional perfusion, in a high-risk micro vascular bed, gastric intraluminal tonometry should identify perfusion states of compensated or uncompensated shock during hemodynamic resus citation of the critically ill injury patient. A low pHi appears to be a marker of postresuscitative morbidity and subsequent increased leng th of stay.