title: Failure of splanchnic resuscitation in the acutely injured trauma patient correlates with multiple organ system failure and length of stay in the ICU.
abstract: BACKGROUND
  The purpose of our study was to evaluate the relationship between the state of splanchnic perfusion and morbidity and mortality in the hemodynamically unstable trauma patient acutely resuscitated in the ICU.
  
  
  METHODS
  Gastric intramucosal pH (pHi) was monitored in a blinded fashion in 19 consecutive critically ill trauma patients with evidence of systemic hypoperfusion (arterial pH [pHa] <7.35, base excess >2.3 mmol/L, lactic acid >2.3 mEq/L) who received right heart catheters to guide resuscitation and subsequent hemodynamic monitoring.
  
  
  METHODS
  Prospective randomized consecutive series with retrospective analysis of data.
  
  
  METHODS
  University hospital, surgical ICU.
  
  
  RESULTS
  The mean values of APACHE II (acute physiology and chronic health evaluation) Injury Severity Score, pHa, arterial base excess, cardiac index, oxygen delivery index, and oxygen consumption index by 24 h were similar (Student's t test, p>0.1) between survivors and nonsurvivors and between those who developed at most a single (SOF) vs multiple organ system failure (MOSF). Supranormal oxygen delivery and utilization parameters were evenly distributed among survivors and nonsurvivors and patients with SOF and MOSF (chi2, p>0.5). Ten patients had a pHi <7.32 and nine patients had a pHi > or = 7.32 by 24 h. Fifty percent of patients with a pHi <7.32 died, compared with 11% of patients with a pH > or = 7.32 (chi2, p=0.07). Sixty percent of patients with a pHi <7.32 developed MOSF compared with 11% of patients with a pHi > or = 7.32 (chi2, p=0.03). The one patient who developed MOSF and died in the pHi > or = 7.32 cohort suffered from massive head trauma and had all futile medical interventions halted. No other patients who achieved a pH > or = 7.32 by hour 24 developed MOSF. Survivors with a pHi <7.32 at hour 24 had an increased ICU stay (pHi <7.32=46+/-15 days, pHi > or = 7.32=13+/-9 days; p<0.01). A pHi <7.32 carried a relative risk of 4.5 for death and 5.4 for the occurrence of MOSF.
  
  
  CONCLUSIONS
  Attainment of a pHi > or = 7.32 at hour 24 carried a significantly reduced likelihood of MOSF. Being an inference of the state of regional perfusion, in a high-risk microvascular bed, gastric intraluminal tonometry should identify perfusion states of compensated or uncompensated shock during hemodynamic resuscitation of the critically ill injury patient. A low pHi appears to be a marker of postresuscitative morbidity and subsequent increased length of stay.
authors.affiliation: Department of Surgery, The Ryder Trauma Center, University of Miami/Jackson Memorial Medical Center, FL, USA.
authors.forename: O C
authors.initials: OC
authors.lastname: Kirton
authors.forename: J
authors.initials: J
authors.lastname: Windsor
authors.forename: R
authors.initials: R
authors.lastname: Wedderburn
authors.forename: J
authors.initials: J
authors.lastname: Hudson-Civetta
authors.forename: D V
authors.initials: DV
authors.lastname: Shatz
authors.forename: N R
authors.initials: NR
authors.lastname: Mataragas
authors.forename: J M
authors.initials: JM
authors.lastname: Civetta
mesh_terms: D003422:Critical Care; D016638:Critical Illness; D005260:Female; D006439:Hemodynamics; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D008297:Male; D009102:Multiple Organ Failure / Q000503:physiopathology*; D011446:Prospective Studies; D012151:Resuscitation; D012680:Sensitivity and Specificity; D013152:Splanchnic Circulation; D014947:Wounds and Injuries / Q000503:physiopathology* / Q000628:therapy*