Samuelsson Anders, Steinvall Ingrid, Sjöberg Folke
Department of Intensive Care, Linköping University Hospital, Linköping, Sweden.
Crit Care. 2006;10(6):R172. doi: 10.1186/cc5124.
Established fluid treatment formulas for burn injuries have been challenged as studies have shown the presence of tissue hypoxia during standard resuscitation. Such findings suggest monitoring at the tissue level. This study was performed in patients with major burn injuries to evaluate the microdialysis technique for the continuous assessment of skin metabolic changes during fluid resuscitation and up to four days postburn.
We conducted an experimental study in patients with a burn injury, as represented by percentage of total body surface area burned (TBSA), of more than 25% in a university eight-bed burns intensive care unit serving about 3.5 million inhabitants. Six patients with a median TBSA percentage of 59% (range 33.5% to 90%) and nine healthy controls were examined by intracutaneous MD, in which recordings of glucose, pyruvate, lactate, glycerol, and urea were performed.
Blood glucose concentration peaked on day two at 9.8 mmol/l (6.8 to 14.0) (median and range) and gradually declined on days three and four, whereas skin glucose in MD continued to increase throughout the study period with maximum values on day four, 8.7 mmol/l (4.9 to 11.0). Controls had significantly lower skin glucose values compared with burn patients, 3.1 mmol/l (1.5 to 4.6) (p < 0.001). Lactate from burn patients was significantly higher than controls in both injured and uninjured skin (MD), 4.6 mmol/l (1.3 to 8.9) and 3.8 mmol/l (1.6 to 7.5), respectively (p < 0.01). The skin lactate/pyruvate ratio (MD) was significantly increased in burn patients on all days (p < 0.001). Skin glycerol (MD) was significantly increased at days three and four in burn patients compared with controls (p < 0.01).
Despite a strategy that fulfilled conventional goals for resuscitation, there were increased lactate/pyruvate ratios, indicative of local acidosis. A corresponding finding was not recorded systemically. We conclude that MD is a promising tool for depicting local metabolic processes that are not fully appreciated when examined systemically. Because the local response in glucose, lactate, and pyruvate metabolism seems to differ from that recorded systemically, this technique may offer a new method of monitoring organs.
由于研究表明在标准复苏过程中存在组织缺氧，已有的烧伤液体治疗公式受到了挑战。这些发现提示需要在组织水平进行监测。本研究对重度烧伤患者进行，以评估微透析技术在液体复苏期间及烧伤后四天内连续评估皮肤代谢变化的情况。
我们在一所为约350万居民服务的大学八床位烧伤重症监护病房，对烧伤面积超过25%（以烧伤总面积百分比表示，TBSA）的患者进行了一项实验研究。对6例中位TBSA百分比为59%（范围33.5%至90%）的患者和9名健康对照者进行了皮内微透析检查，记录葡萄糖、丙酮酸、乳酸、甘油和尿素。
血糖浓度在第二天达到峰值，为9.8 mmol/l（6.8至14.0）（中位数和范围），在第三天和第四天逐渐下降，而微透析中的皮肤葡萄糖在整个研究期间持续升高，在第四天达到最大值，为8.7 mmol/l（4.9至11.0）。与烧伤患者相比，对照组的皮肤葡萄糖值显著较低，为3.1 mmol/l（1.5至4.6）（p < 0.001）。烧伤患者受伤和未受伤皮肤（微透析）中的乳酸均显著高于对照组，分别为4.6 mmol/l（1.3至8.9）和3.8 mmol/l（1.6至7.5）（p < 0.01）。烧伤患者各天的皮肤乳酸/丙酮酸比值（微透析）均显著升高（p < 0.001）。与对照组相比，烧伤患者在第三天和第四天的皮肤甘油（微透析）显著升高（p < 0.01）。
尽管采用了符合传统复苏目标的策略，但乳酸/丙酮酸比值仍升高，提示局部酸中毒。全身未记录到相应发现。我们得出结论，微透析是描绘局部代谢过程的一种有前景的工具，而这些过程在全身检查时并未得到充分认识。由于葡萄糖、乳酸和丙酮酸代谢的局部反应似乎与全身记录的不同，该技术可能提供一种监测器官的新方法。
