Shoemaker W C, Appel P L, Kram H B
Department of Surgery, King-Drew Medical Center, Los Angeles, CA 90059.
Crit Care Med. 1991 May;19(5):672-88. doi: 10.1097/00003246-199105000-00014.
Increased cardiac index, oxygen delivery (DO2), and oxygen consumption (VO2) patterns were shown to characterize the physiologic status of surviving high-risk surgical patients, and indicate increased metabolic needs; relatively normal DO2 and VO2 values were found to characterize the sequential pattern of nonsurvivors who developed an early oxygen debt followed by lethal organ failure. The cardiac index, DO2, and VO2 values empirically determined from survivors' patterns were shown to improve outcome in prospective randomized trials. The present study considers these criteria to evaluate the tissue perfusion status as well as the effects of therapy on tissue perfusion and oxygenation.
To summarize new information on the temporal patterns of DO2, VO2, and oxygen debt on outcome and the effects of fluids and inotropes on these patterns in a wide range of clinical, temporal, and physiologic conditions.
Descriptive analysis based on data gathered prospectively using a specified protocol.
High-risk patients with accidental or elective surgical trauma, and patients with or without sepsis or septic shock and organ failure.
University-run county hospital with a large trauma service.
Fluids, dobutamine, and dopamine at various times and at various doses throughout critical illness of postoperative, posttraumatic, septic, and hypovolemic patients with and without lethal and nonlethal organ failure.
The pattern of DO2 plotted against the corresponding VO2 values in 437 consecutive critically ill surgical patients showed a wide variability and poor correlation probably because complex clinical conditions may obscure the supply-dependent and supply-independent VO2 relationships observed in normal dogs bled or given bacterial infusions. However, the use of specific therapy by well-defined protocols was shown to provide objective evidence of efficacy. Significant increases in DO2 and VO2 were previously shown after whole blood, packed red cells, and colloid administration, but not after crystalloid administration. Dobutamine administration in 715 circumstances in postoperative, traumatic, septic patients and patients with adult respiratory distress syndrome, renal failure, and multiple organ failure significantly improved DO2 and VO2. Dopamine under comparable conditions produced less improvement in DO2 and VO2 than that of dobutamine; most of the VO2 changes were not significant.
The monitored patterns of cardiac index, DO2, and VO2 may be used to evaluate the adequacy of tissue perfusion as well as the relative effectiveness of alternative therapies. Second, these physiologic criteria may be used to titrate therapy in order to achieve optimal outcome. Third, after colloids optimally expand the plasma volume, dobutamine may be used to enhance flow and the distribution of flow in order to improve tissue oxygenation. Vasodilators may be used when hypertensive episodes occur or there is an inadequate response to inotropic agents. Vasopressors are used as a last resort, usually in the terminal or preterminal state.
心脏指数、氧输送（DO2）和氧消耗（VO2）模式的增加被证明是存活的高危手术患者生理状态的特征，并表明代谢需求增加；相对正常的DO2和VO2值被发现是未存活者的连续模式特征，这些患者早期出现氧债，随后发生致命的器官衰竭。在前瞻性随机试验中，根据幸存者模式经验性确定的心脏指数、DO2和VO2值被证明可改善预后。本研究考虑这些标准来评估组织灌注状态以及治疗对组织灌注和氧合的影响。
总结在广泛的临床、时间和生理条件下，DO2、VO2和氧债的时间模式对预后的新信息，以及液体和血管活性药物对这些模式的影响。
基于使用特定方案前瞻性收集的数据进行描述性分析。
意外或择期手术创伤的高危患者，以及有或没有脓毒症、脓毒性休克和器官衰竭的患者。
拥有大型创伤服务的大学附属县医院。
在术后、创伤后、脓毒症和低血容量患者的危重病期间，在不同时间和不同剂量给予液体、多巴酚丁胺和多巴胺，这些患者有或没有致命和非致命的器官衰竭。
对437例连续的危重病手术患者，将DO2模式与相应的VO2值进行绘制，结果显示差异很大且相关性较差，这可能是因为复杂的临床状况可能掩盖了在正常犬类放血或给予细菌输注时观察到的氧供依赖性和氧供非依赖性VO2关系。然而，通过明确的方案使用特定治疗被证明可提供疗效的客观证据。先前显示，输注全血、浓缩红细胞和胶体后DO2和VO2显著增加，但输注晶体液后未增加。在715例术后、创伤后、脓毒症患者以及患有成人呼吸窘迫综合征、肾衰竭和多器官衰竭的患者中使用多巴酚丁胺，显著改善了DO2和VO2。在类似条件下，多巴胺对DO2和VO2的改善不如多巴酚丁胺；大多数VO2变化不显著。
监测的心脏指数、DO2和VO2模式可用于评估组织灌注的充分性以及替代疗法的相对有效性。其次，这些生理标准可用于调整治疗以实现最佳预后。第三，在胶体最佳地扩充血浆容量后，可使用多巴酚丁胺来增加血流和血流分布，以改善组织氧合。当发生高血压发作或对血管活性药物反应不足时，可使用血管扩张剂。血管升压药作为最后手段使用，通常在终末期或濒死期。
