McKinley Bruce A, Kozar Rosemary A, Cocanour Christine S, Valdivia Alicia, Sailors R Matthew, Ware Drue N, Moore Frederick A
Department of Surgery, University of Texas-Houston Medical School, 77030, USA.
J Trauma. 2002 Nov;53(5):825-32. doi: 10.1097/00005373-200211000-00004.
Shock resuscitation is integral to early management of severely injured patients. Our standardized shock resuscitation protocol, developed in 1997 and implemented as a computerized intensive care unit (ICU) bedside decision support tool in 2000, used oxygen delivery index (Do I) > or = 600 mL/min/m as the intervention endpoint. In a recent publication, Shoemaker et al. refuted positive outcome effect of early supranormal Do (i.e., Do I > or = 600) resuscitation. In response to and because of ongoing concern for excessive volume loading, we decreased our Do I endpoint from 600 to 500. Our hypothesis was that by decreasing the Do I endpoint, less crystalloid would be administered. We compare resuscitation responses to the protocol with goals of Do I > or = 600 versus 500 in two patient cohorts.
A standardized protocol was used to direct bedside decisions for resuscitation of patients with major injury (Injury Severity Score > 15), blood loss (> or = 6 units of packed red blood cells), metabolic stress (base deficit > or = 6 mEq/L), and no severe brain injury. The protocol logic is to attain and maintain Do I > or = a specified goal for the first 24 ICU hours using primarily blood and volume loading. Two cohorts were compared: Do I > or = 500 (18 patients admitted February-August 2001) versus Do I > or = 600 (18 patients admitted during 2000 age and gender matched with the Do I > or = 500 group). Data were analyzed using analysis of variance, chi, and t tests (p < 0.05).
Both groups had similar demographics (age 30 +/- 3 years; 78% men; Injury Severity Score 27 +/- 3), hemodynamics, and severity of shock at start of resuscitation in the ICU. Resuscitation response was Do I increase to > or = 600 for both cohorts within approximately 12 hours. Throughout the 24-hour ICU process, the Do I > or = 500 cohort received less lactated Ringer's volume than the Do I > or = 600 cohort (total of 8 +/- 1 vs. 12 +/- 2 L; p < 0.05) and tended to receive less blood transfusion (total of 3 +/- 1 vs. 5 +/- 1 units of packed red blood cells).
Shock resuscitation using Do I > or = 500 was indistinguishable from Do I > or = 600 mL/min/m. Less volume loading was required to attain and maintain Do I > or = 500 than 600 using computerized protocol technology to standardize resuscitation during the first 24 ICU hours.
休克复苏是重伤患者早期治疗的重要组成部分。我们于1997年制定了标准化休克复苏方案，并于2000年作为计算机化重症监护病房（ICU）床边决策支持工具实施，该方案将氧输送指数（DoI）≥600 mL/min/m²作为干预终点。在最近的一篇出版物中，Shoemaker等人驳斥了早期超正常DoI（即DoI≥600）复苏的积极预后效果。由于持续关注过量液体负荷，我们将DoI终点从600降至500。我们的假设是，通过降低DoI终点，将减少晶体液的输注量。我们比较了两个患者队列对该方案的复苏反应，其目标分别为DoI≥600和DoI≥500。
采用标准化方案指导对重伤（损伤严重度评分>15）、失血（≥6单位浓缩红细胞）、代谢应激（碱缺失≥6 mEq/L）且无严重脑损伤患者的床边复苏决策。该方案的逻辑是在ICU的头24小时内主要通过输血和液体负荷来达到并维持DoI≥特定目标。比较了两个队列：DoI≥500（2001年2月至8月收治的18例患者）与DoI≥600（2000年收治的18例患者，年龄和性别与DoI≥500组匹配）。使用方差分析、卡方检验和t检验进行数据分析（p<0.05）。
两组在ICU复苏开始时的人口统计学特征（年龄30±3岁；78%为男性；损伤严重度评分27±3）、血流动力学和休克严重程度相似。两个队列的复苏反应均为在约12小时内DoI增加至≥600。在整个24小时的ICU过程中，DoI≥500队列接受的乳酸林格液量少于DoI≥600队列（总量分别为8±1 L和12±2 L；p<0.05），且输血倾向较少（浓缩红细胞总量分别为3±1单位和5±1单位）。
使用DoI≥500进行休克复苏与使用DoI≥600 mL/min/m²进行复苏无明显差异。在ICU头24小时内，使用计算机化方案技术标准化复苏时，达到并维持DoI≥500所需的液体负荷量比DoI≥600时少。
