Scherr Benedikt F, Wendel-Garcia Pedro D, Bruns Hannes, Steiger Peter, Schuepbach Reto A, Kim Bong-Sung, Vasella Mauro, Camen Giovanni, Buehler Philipp Karl
Department of Intensive Care Medicine, Cantonal Hospital Winterthur, Winterthur, Switzerland.
Institute of Intensive Care, University Hospital Zurich, Zurich, Switzerland.
Burns. 2025 Jun 24;51(8):107585. doi: 10.1016/j.burns.2025.107585.
Guiding fluid therapy in severely burned patients presents complex challenges, combining elements of both distributive and hypovolemic shock, accompanied by cardiovascular dysfunction. Whereas parts of hemodynamic assessment in septic shock such as central venous oxygen saturation (ScvO2) and the arterial-venous carbon dioxide (CO2) partial pressure difference (ΔpCO2 = pcvCO2 - paCO2) can both be used as indicators of hypoperfusion, they are not part of the standard clinical assessment of severely burned patients. The aim of this retrospective study was thus to investigate whether the ΔpCO2 and ScvO2 in severely burned patients correlates with fluid administration and mortality.
Retrospective analysis of severely burned patients with burns larger than 20 % total body surface area (TBSA) admitted between 01/2017 and 06/2021 to the Burns Center of the University Hospital Zurich, Switzerland. Patients were treated according to international guidelines and in-house standards and ΔpCO2 and ScvO2 were assessed at least once within the first 24 h of intensive care unit admission.
In total 69 patients were included in this analysis. The median ΔpCO2 and ScvO2 were 1.16 kPa [inter-quartile range IQR, 0.82 - 1.50] and 76 % [IQR, 71 - 81]. This translated to an abnormally elevated ΔpCO2 (>0.8 kPa) in 53 (77 %) and an abnormally reduced ScvO2 (<70 %) in 13 (19 %) patients. Initial ΔpCO2, but not ScvO2, was non-linearly associated with intravenous fluid administration in the following 24 h (estimate 9.6 L [95 % confidence interval CI, 4.1 - 15.2], p = 0.001) and 48 h (estimate 6.0 L [95 % CI, 0.3 - 11.8], p = 0.039). Both initial ΔpCO2 (logarithmic odds ratio OR 4.3 [95 % CI, 1.1 - 20.9], p = 0.048) as well as ScvO2 (OR 0.1 [95 % CI, 0 - 0.42], p = 0.034) were non-linearly associated with in-hospital mortality. However, the best association with mortality was achieved by combining ΔpCO2 and ScvO2, with patients presenting with abnormalities in both ΔpCO2 and ScvO2 having a predicted mortality of 46 % [95 % CI, 23-71].
In severely burned patients, both ΔpCO2 and ScvO2 are associated with the extent and severity of burns as well as with in-hospital mortality. However, only ΔpCO2 seems to possess potential as a predictor of fluid administration. A multimodal approach to fluid resuscitation including both parameters may show promise in severely burned patients; however, further prospective studies are required to define optimal thresholds and validate its integration into clinical fluid resuscitation practice.
指导严重烧伤患者的液体治疗面临复杂挑战，因其兼具分布性休克和低血容量性休克的因素，并伴有心血管功能障碍。虽然脓毒症休克的部分血流动力学评估指标，如中心静脉血氧饱和度（ScvO2）和动静脉二氧化碳（CO2）分压差值（ΔpCO2 = 中心静脉血CO2分压 - 动脉血CO2分压）均可作为低灌注的指标，但它们并非严重烧伤患者标准临床评估的一部分。因此，这项回顾性研究的目的是调查严重烧伤患者的ΔpCO2和ScvO2是否与液体输注量和死亡率相关。
对2017年1月至2021年6月间收治于瑞士苏黎世大学医院烧伤中心、烧伤总面积大于20%体表面积（TBSA）的严重烧伤患者进行回顾性分析。患者按照国际指南和内部标准进行治疗，且在重症监护病房入院后的头24小时内至少评估一次ΔpCO2和ScvO2。
本分析共纳入69例患者。ΔpCO2中位数为1.16 kPa [四分位间距IQR，0.82 - 1.50]，ScvO2中位数为76% [IQR，71 - 81]。这意味着53例（77%）患者的ΔpCO2异常升高（>0.8 kPa），13例（19%）患者的ScvO2异常降低（<70%）。初始ΔpCO2而非ScvO2与随后24小时（估计值9.6 L [95%置信区间CI，4.1 - 15.2]，p = 0.001）和48小时（估计值6.0 L [95% CI，0.3 - 11.8]，p = 0.039）的静脉输液量呈非线性相关。初始ΔpCO2（对数比值比OR 4.3 [95% CI，1.1 - 20.9]，p = 0.048）以及ScvO2（OR 0.1 [95% CI，0 - 0.42]，p = 0.034）均与院内死亡率呈非线性相关。然而，将ΔpCO2和ScvO2结合可实现与死亡率的最佳关联，ΔpCO2和ScvO2均异常的患者预测死亡率为46% [95% CI，23 - 71]。
在严重烧伤患者中，ΔpCO2和ScvO2均与烧伤程度和严重程度以及院内死亡率相关。然而，似乎只有ΔpCO2具有作为液体输注预测指标的潜力。包括这两个参数的多模式液体复苏方法在严重烧伤患者中可能显示出前景；然而，需要进一步的前瞻性研究来确定最佳阈值并验证其纳入临床液体复苏实践的可行性。
