Calvete José O, Schonhorst Leonardo, Moura Diego M, Friedman Gilberto
Universidade de Passo Fundo - Hospital Universitário São Vicente de Paulo, Passo Fundo, RS.
Rev Assoc Med Bras (1992). 2008 Mar-Apr;54(2):116-21. doi: 10.1590/s0104-42302008000200012.
This prospective non-interventional study intended to assess the prognostic value of gastric intramucosal acidosis in patients with severe trauma admitted to a medical/surgical ICU.
Gastric tonometer catheters were introduced to measure air PCO2 level (Tonocap device) in forty consecutive critically ill trauma patients. Gastric intramucosal pH, air PCO2 gradient, lactate and acid-base parameters were measured at admission and at 6, 12 and 24 h thereafter.
The median age, mean APACHE II and SOFA scores were higher in nonsurvivors than in survivors (p<0.05). There were significant differences in the PCO2 gradient between survivors and nonsurvivors at 12 and 24 hours (10+/-7 vs. 24+/-19 mmHg, 13+/-16 vs. 29+/-25 mmHg; p<0.05). Gastric intramucosal pH values were lower in nonsurvivors than in survivors, on admission and after 12 or 24 hours (p<0.05). Arterial pH and bicarbonate were lower, lactate concentration higher, and base excess more negative in nonsurvivors. Prediction of outcome (mortality and MODS) at 24 hours of ICU assessed by their ROC curves was similar (p=NS). At 24 hours, air PCO2 gradient > 18 mmHg carried a relative risk of 4.6 for death, slightly higher than a HCO3 <20 mEq/L (RR=4.29) or base excess of <-2 mmol/L (RR=3.65).
Bicarbonate, base deficit, lactate, gastric intramucosal pH and PCO2 gradient discriminate survivors from nonsurvivors of major trauma. A critical air PCO2 gradient carried the greatest relative risk for death at 24 hours of ICU. Inadequate regional blood flow as detected by a critical PCO2 gradient seems to contribute to morbidity and mortality of severe trauma patients.
这项前瞻性非干预性研究旨在评估入住内科/外科重症监护病房（ICU）的严重创伤患者胃黏膜内酸中毒的预后价值。
对40例连续入住ICU的重症创伤患者插入胃张力计导管以测量气袋二氧化碳分压水平（Tonocap设备）。在入院时以及此后6、12和24小时测量胃黏膜内pH值、气袋二氧化碳分压梯度、乳酸水平和酸碱参数。
非幸存者的年龄中位数、平均急性生理与慢性健康状况评分系统（APACHE II）和序贯器官衰竭评估（SOFA）评分高于幸存者（p<0.05）。幸存者与非幸存者在12和24小时时的二氧化碳分压梯度存在显著差异（10±7对24±19 mmHg，13±16对29±25 mmHg；p<0.05）。非幸存者在入院时以及12或24小时后的胃黏膜内pH值低于幸存者（p<0.05）。非幸存者的动脉血pH值和碳酸氢盐水平较低，乳酸浓度较高，碱剩余更负。通过其ROC曲线评估的ICU 24小时时的预后（死亡率和多器官功能障碍综合征）预测相似（p=无显著性差异）。在24小时时，气袋二氧化碳分压梯度>18 mmHg的死亡相对风险为4.6，略高于碳酸氢盐<20 mEq/L（RR=4.29）或碱剩余<-2 mmol/L（RR= 3.65）。
碳酸氢盐、碱缺失、乳酸、胃黏膜内pH值和二氧化碳分压梯度可区分严重创伤的幸存者与非幸存者。在ICU 24小时时，临界气袋二氧化碳分压梯度的死亡相对风险最高。临界二氧化碳分压梯度检测到的局部血流不足似乎导致严重创伤患者的发病和死亡。
