Light T D, Jeng James C, Jain A K, Jablonski K A, Kim D E, Phillips T M, Rizzo A G, Jordan M H
Department of Surgery, Washington Hospital Center, Washington, DC 20010, USA.
J Burn Care Rehabil. 2004 Jan-Feb;25(1):33-44. doi: 10.1097/01.BCR.0000105344.84628.C8.
Real-time metabolic monitoring of varied vascular beds provides the raw data necessary to conduct ultraprecise burn shock resuscitation based on second-by-second assessment of regional tissue perfusion. It also illustrates shortcomings of current clinical practices. Arterial base deficit was continuously monitored during 11 clinical resuscitations of patients suffering burn shock using a Paratrend monitor. Separately, in a 30% TBSA rat burn model (N = 70), three Paratrend monitors simultaneously recorded arterial blood gas and tissue pCO2 of the burn wound and colonic mucosa during resuscitation at 0, 2, 4, 6, and 8 ml/kg/%TBSA. Paratrend data were analyzed in conjunction with previously reported laser Doppler images of actual burn wound capillary perfusion. With current clinical therapy, continuous monitoring of arterial base deficit revealed repetitive cycles of resolution/worsening/resolution during burn shock resuscitation. In the rat model, tissue pCO2 in both burn wounds and splanchnic circulation differed depending on the rate of fluid resuscitation (P <.01 between sham and 0 ml/kg/%TBSA and between 2 ml/kg/%TBSA and 4 ml/kg/%TBSA). Burn wound pCO2 values correlated well with laser Doppler determination of actual capillary perfusion (rho = -.48, P <.01). The following conclusions were reached: 1). Gratuitous and repetitive ischemia-reperfusion-ischemia cycles plague current clinical therapy as demonstrated by numerous "false starts" in the resolution of arterial base deficit; 2). in a rat model, real-time monitoring of burn wound and splanchnic pCO2 demonstrate a dose-response relationship with rate of fluid administration; and 3). burn wound and splanchnic pCO2 are highly correlated with direct measurement of burn wound capillary perfusion by laser Doppler imager. Either technique can serve as a resuscitation endpoint for real-time feedback-controlled ultraprecise resuscitation.
对不同血管床进行实时代谢监测可提供必要的原始数据，以便基于对局部组织灌注的逐秒评估来进行超精确的烧伤休克复苏。这也揭示了当前临床实践的不足之处。在11例烧伤休克患者的临床复苏过程中，使用Paratrend监测仪持续监测动脉碱缺失。另外，在一个30%体表面积的大鼠烧伤模型（N = 70）中，在以0、2、4、6和8 ml/kg/%体表面积的速度进行复苏期间，三台Paratrend监测仪同时记录烧伤创面和结肠黏膜的动脉血气及组织pCO₂。将Paratrend数据与先前报道的实际烧伤创面毛细血管灌注的激光多普勒图像相结合进行分析。采用当前的临床治疗方法，对动脉碱缺失的持续监测显示，在烧伤休克复苏过程中存在反复的缓解/恶化/缓解周期。在大鼠模型中，烧伤创面和内脏循环中的组织pCO₂因液体复苏速度而异（假手术组与0 ml/kg/%体表面积组之间以及2 ml/kg/%体表面积组与4 ml/kg/%体表面积组之间P <.01）。烧伤创面pCO₂值与激光多普勒测定的实际毛细血管灌注密切相关（rho = -.48，P <.01）。得出以下结论：1）。当前临床治疗中存在不必要且反复的缺血-再灌注-缺血周期，如动脉碱缺失缓解过程中出现的众多“错误开端”所示；2）。在大鼠模型中，对烧伤创面和内脏pCO₂的实时监测显示其与液体给药速度呈剂量反应关系；3）。烧伤创面和内脏pCO₂与激光多普勒成像仪直接测量的烧伤创面毛细血管灌注高度相关。这两种技术均可作为实时反馈控制的超精确复苏的复苏终点。
