Endpoints of resuscitation of critically injured patients: Normal or supranormal? A prospective randomized trial

Objective To evaluate the effect of early optimization in the survival of s everely injured patients. Summary Background Data It is unclear whether supranormal ("optimal") hemod ynamic values should serve as endpoints of resuscitation or simply as marke rs of the physiologic reserve of critically injured patients. The failure o f optimization to produce improved survival in some randomized controlled t rials may be associated with delays in starting the attempt to reach optima l goals. There are limited controlled data on trauma patients. Methods Seventy-five consecutive severely injured patients with shock resul ting from bleeding and without major intracranial or spinal cord trauma wer e randomized to resuscitation, starting immediately after admission, to eit her normal values of systolic blood pressure, urine output, base deficit, h emoglobin, and cardiac index (control group, 35 patients) or optimal values (cardiac index >4.5 L/min/m(2), ratio of transcutaneous oxygen tension to fractional inspired oxygen >20D, oxygen delivery index >600 mL/min/m(2), an d oxygen consumption index >170 mL/min/m(2); optimal group, 40 patients). I nitial cardiac output monitoring was done noninvasively by bioimpedance and , subsequently, invasively by thermodilution. Crystalloids, colloids, blood , inotropes, and vasopressors were used by predetermined algorithms. Results Optimal values were reached intentionally by 70% of the optimal pat ients and spontaneously by 40% of the control patients. There was no differ ence in rates of death (15% optimal vs. 11% control), organ failure, sepsis , or the length of intensive care unit or hospital stay between the two gro ups, Patients from both groups who achieved optimal values had better outco mes than patients who did not. The death rate was 30% among patients who ac hieved optimal values compared with 30% among patients who did not. Age you nger than 40 years was the only independent predictive factor of the abilit y to reach optimal values. Conclusions Severely injured patients who can achieve optimal hemodynamic v alues are more likely to survive than those who cannot, regardless of the r esuscitation technique. in this study, attempts at early optimization did n ot improve the outcome of the examined subgroup of severely injured patient s.