Velmahos G C, Demetriades D, Shoemaker W C, Chan L S, Tatevossian R, Wo C C, Vassiliu P, Cornwell E E, Murray J A, Roth B, Belzberg H, Asensio J A, Berne T V
Department of Surgery, Division of Trauma and Critical Care, and the Department of Biostatistics and Outcomes Research, University of Southern California, Los Angeles, California, USA.
Ann Surg. 2000 Sep;232(3):409-18. doi: 10.1097/00000658-200009000-00013.
To evaluate the effect of early optimization in the survival of severely injured patients.
It is unclear whether supranormal ("optimal") hemodynamic values should serve as endpoints of resuscitation or simply as markers of the physiologic reserve of critically injured patients. The failure of optimization to produce improved survival in some randomized controlled trials may be associated with delays in starting the attempt to reach optimal goals. There are limited controlled data on trauma patients.
Seventy-five consecutive severely injured patients with shock resulting from bleeding and without major intracranial or spinal cord trauma were randomized to resuscitation, starting immediately after admission, to either normal values of systolic blood pressure, urine output, base deficit, hemoglobin, and cardiac index (control group, 35 patients) or optimal values (cardiac index >4.5 L/min/m2, ratio of transcutaneous oxygen tension to fractional inspired oxygen >200, oxygen delivery index >600 mL/min/m2, and oxygen consumption index >170 mL/min/m2; optimal group, 40 patients). Initial cardiac output monitoring was done noninvasively by bioimpedance and, subsequently, invasively by thermodilution. Crystalloids, colloids, blood, inotropes, and vasopressors were used by predetermined algorithms.
Optimal values were reached intentionally by 70% of the optimal patients and spontaneously by 40% of the control patients. There was no difference 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 groups. Patients from both groups who achieved optimal values had better outcomes than patients who did not. The death rate was 0% among patients who achieved optimal values compared with 30% among patients who did not. Age younger than 40 years was the only independent predictive factor of the ability to reach optimal values.
Severely injured patients who can achieve optimal hemodynamic values are more likely to survive than those who cannot, regardless of the resuscitation technique. In this study, attempts at early optimization did not improve the outcome of the examined subgroup of severely injured patients.
评估早期优化治疗对重伤患者生存的影响。
目前尚不清楚超常（“最佳”）血流动力学值应作为复苏终点，还是仅作为重伤患者生理储备的标志物。在一些随机对照试验中，优化治疗未能提高生存率，可能与开始尝试达到最佳目标的延迟有关。关于创伤患者的对照数据有限。
75例因出血导致休克且无严重颅内或脊髓创伤的连续重伤患者，入院后立即随机分为两组进行复苏治疗，一组为收缩压、尿量、碱缺失、血红蛋白和心脏指数达到正常水平（对照组，35例患者），另一组为达到最佳值（心脏指数>4.5L/min/m²、经皮氧分压与吸入氧分数比值>200、氧输送指数>600mL/min/m²、氧消耗指数>170mL/min/m²；最佳组，40例患者）。初始心输出量监测通过生物电阻抗无创进行，随后通过热稀释法有创进行。根据预定算法使用晶体液、胶体液、血液、血管活性药物和血管加压药。
最佳组70%的患者有意达到了最佳值，对照组40%的患者自发达到了最佳值。两组在死亡率（最佳组15% vs. 对照组11%）、器官衰竭、脓毒症以及重症监护病房或住院时间方面无差异。两组中达到最佳值的患者比未达到最佳值的患者预后更好。达到最佳值的患者死亡率为0%，未达到最佳值的患者死亡率为30%。年龄小于40岁是达到最佳值能力的唯一独立预测因素。
无论复苏技术如何，能够达到最佳血流动力学值的重伤患者比无法达到的患者更有可能存活。在本研究中，早期优化治疗并未改善所研究的重伤患者亚组的预后。
