Dunham C M, Frankenfield D, Belzberg H, Wiles C E, Cushing B, Grant Z
Department of Surgery, MIEMSS Shock Trauma Center, Baltimore, MD 21201.
Crit Care Med. 1994 Apr;22(4):667-72.
To assess whether variables reflective of early metabolic responses to injury are predictors of outcome in critically ill trauma patients.
Clinical inception cohort study comparing conventional measures of injury severity with early host response markers for the correlation of each with outcome. These data are prospectively collected in a group of patients being evaluated in a nutritional support investigation.
Intensive care unit (ICU) of a major Level I trauma center.
Seventeen blunt trauma patients, aged 18 to 60 yrs with an Injury Severity Score of > or = 15, requiring early mechanical ventilation.
Blood and urine samples were routinely obtained from patients undergoing nutritional support by one of three routes.
Conventional assessment was consistent with moderate severity and variation: Injury Severity Score, 41 +/- 15; Glasgow Coma Score, 11 +/- 4; admission circulating lactate concentration, 4.8 +/- 2.2 mmol/L; and first 24-hr transfusion requirement, 3.1 +/- 2.9 L. The mean concentrations of inflammatory marker during the first week were: cholesterol, 2.67 +/- 0.80 mmol/L (103.2 +/- 31 mg/dL); C-reactive protein, 23 +/- 11 mg/dL; transferrin, 1.44 +/- 0.47 g/L; glucose, 9.21 +/- 2.27 mmol/L (166 +/- 41 mg/dL); albumin, 26 +/- 5 g/L; and nitrogen loss, 24 +/- 9 g/d. Hospital outcome variables were: ventilator days, 17 +/- 7; ICU days, 26 +/- 10; hospital days, 38 +/- 15; occurrence rate of adult respiratory distress syndrome (ARDS), 35%; infections, 82%; multiple organ failure, 71%; and total of hospital plus professional charges, $125,000 +/- $56,000. A significant (p < .05), but weak, correlation existed between all seven outcome variables and the inflammatory markers: ventilator days with cholesterol and C-reactive protein; ICU days with transferrin; total stay with cholesterol; ARDS with C-reactive protein; infections with glucose, cholesterol, and nitrogen loss; multiple organ failure with albumin and C-reactive protein; and financial charges with glucose. However, a significant correlation existed between only two of seven outcome variables and conventional measures of severity: multiple organ failure with lactate and financial charges with transfusion requirement.
Readily obtainable inflammatory marker measurements may better reflect the summation effects of the early perfusion deficit and tissue injury in the blunt trauma patient compared with conventional measures of injury severity.
评估反映对损伤的早期代谢反应的变量是否为重症创伤患者预后的预测指标。
临床起始队列研究，比较损伤严重程度的传统测量指标与早期宿主反应标志物，以分析二者与预后的相关性。这些数据是在一项营养支持调查中对一组患者进行前瞻性收集的。
一家大型一级创伤中心的重症监护病房（ICU）。
17例钝性创伤患者，年龄18至60岁，损伤严重程度评分≥15分，需要早期机械通气。
通过三种途径之一对接受营养支持的患者常规采集血液和尿液样本。
传统评估显示病情严重程度为中度且存在差异：损伤严重程度评分41±15；格拉斯哥昏迷评分11±4；入院时循环乳酸浓度4.8±2.2 mmol/L；最初24小时输血需求量3.1±2.9 L。第一周炎症标志物的平均浓度为：胆固醇2.67±0.80 mmol/L（103.2±31 mg/dL）；C反应蛋白23±11 mg/dL；转铁蛋白1.44±0.47 g/L；葡萄糖9.21±?2.27 mmol/L（166±41 mg/dL）；白蛋白26±5 g/L；氮丢失24±9 g/d。医院预后变量为：机械通气天数17±7；ICU住院天数26±10；住院天数38±15；成人呼吸窘迫综合征（ARDS）发生率35%；感染率82%；多器官功能衰竭发生率71%；医院及专业费用总计125,000±56,000美元。所有七个预后变量与炎症标志物之间存在显著（p<0.05）但较弱的相关性：机械通气天数与胆固醇和C反应蛋白；ICU住院天数与转铁蛋白；总住院时间与胆固醇；ARDS与C反应蛋白；感染与葡萄糖、胆固醇和氮丢失；多器官功能衰竭与白蛋白和C反应蛋白；费用与葡萄糖。然而，七个预后变量中只有两个与传统严重程度测量指标存在显著相关性：多器官功能衰竭与乳酸，费用与输血需求量。
与传统的损伤严重程度测量指标相比，易于获得的炎症标志物测量可能能更好地反映钝性创伤患者早期灌注不足和组织损伤的综合影响。
