Oc. Kirton et al., FAILURE OF SPLANCHNIC RESUSCITATION IN THE ACUTELY INJURED TRAUMA PATIENT CORRELATES WITH MULTIPLE ORGAN SYSTEM FAILURE AND LENGTH OF STAY IN THE ICU, Chest, 113(4), 1998, pp. 1064-1069
Citations number
29
Categorie Soggetti
Respiratory System","Cardiac & Cardiovascular System
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.