Jeng James C, Jaskille Amin D, Lunsford Patricia M, Jordan Marion H
The Burn Center, Washington Hospital Center, Washington, DC, USA.
J Burn Care Res. 2008 Jan-Feb;29(1):49-55. doi: 10.1097/BCR.0b013e31815f59dc.
Improved markers of resuscitation are needed in patients with severe burn injuries. In previous animal and human work, we showed 1) wound hypoperfusion plays a role in burn depth progression, 2) that there are periods of repetitive ischemia and reperfusion which correlate closely to wound hypoperfusion, and 3) that wound and splanchnic bed CO2 measurements are dependent on the adequacy of resuscitation. We and others believe that current markers for resuscitation, urine output (U/O), and mean arterial pressure (MAP), lag behind in reflecting wound perfusion. In this study, we explore whether gastric and tissue tonometry are better in reflecting minute-to-minute changes in wound perfusion in humans. During the 48-hour experimental period, burn wound, gastric, and arterial pH, Pco2, and PaO2 were measured every 6 seconds using a Paratrend 7 monitor in four patients with life threatening burns. Slopes of change were analyzed and a proportion derived relative to pooled data on 5-minute intervals. Serum lactate, U/O, and MAP were recorded. Laser Doppler Imager (LDI) scans were performed on burn areas every 4 hours, allowing real-time determination of burn perfusion. Resuscitation followed current clinical guidelines. All four patients eventually succumbed, one doing so during the observation period. In the remaining three, U/O and MAP goals were met within 2 hours of resuscitation. Our analysis shows cyclic changes in burn wound pH, CO2, and PaO2, gastric CO2, and PaO2, and arterial base deficit (all P < .005). LDI showed cyclic changes in perfusion (P < .0001) which closely mimic the changes in wound pH, gastric CO2, and arterial base deficit. These changes preceded changes in U/O, MAP, and lactate. Although U/O, MAP, and serum lactate reflect changes in burn wound perfusion, they lag behind other markers. Tissue pH and CO2 and gastric CO2 seem to be more timely related to changes in actual burn perfusion.
严重烧伤患者需要更好的复苏指标。在之前的动物和人体研究中，我们发现：1）伤口灌注不足在烧伤深度进展中起作用；2）存在反复缺血和再灌注期，这与伤口灌注不足密切相关；3）伤口和内脏床二氧化碳测量值取决于复苏的充分程度。我们和其他人认为，目前的复苏指标，如尿量（U/O）和平均动脉压（MAP），在反映伤口灌注方面存在滞后。在本研究中，我们探讨了胃张力测定法和组织张力测定法是否能更好地反映人体伤口灌注的每分钟变化。在48小时的实验期内，使用Paratrend 7监护仪每6秒测量4名有生命危险的烧伤患者的烧伤创面、胃以及动脉的pH值、Pco2和PaO2。分析变化斜率，并得出相对于5分钟间隔汇总数据的比例。记录血清乳酸、U/O和MAP。每4小时对烧伤区域进行一次激光多普勒成像（LDI）扫描，以便实时测定烧伤灌注情况。复苏遵循当前临床指南。所有4名患者最终均死亡，其中1例在观察期内死亡。在其余3例中，复苏后2小时内达到了U/O和MAP目标。我们的分析显示，烧伤创面pH值、CO2、PaO2、胃CO2、PaO2以及动脉碱缺失均呈周期性变化（均P < .005）。LDI显示灌注呈周期性变化（P < .0001），这与伤口pH值、胃CO2和动脉碱缺失的变化密切相似。这些变化先于U/O、MAP和乳酸的变化。尽管U/O、MAP和血清乳酸反映了烧伤创面灌注的变化，但它们滞后于其他指标。组织pH值、CO2以及胃CO2似乎与实际烧伤灌注的变化更及时相关。
