Monitoring global volume-related hemodynamic or regional variables after initial resuscitation: What is a better predictor of outcome in critically ill septic patients?
OBJECTIVE
Regional variables of organ dysfunction are thought to be better monitoring variables than global pressure-related hemodynamic variables. Whether a difference exists between regional and global volume-related variables in critically ill patients after resuscitation is unknown.


METHODS
Prospective diagnostic test evaluation.


METHODS
University-affiliated mixed intensive care unit.


METHODS
Twenty-eight critically ill patients.


METHODS
Using standardized resuscitation, hemodynamic optimization was targeted at mean arterial pressure, heart rate, occlusion pressure, cardiac output, systemic vascular resistance, and urine output. Primary outcome variable was in-hospital mortality.


RESULTS
During resuscitation, global volume-related hemodynamic variables were measured simultaneously and compared with regional variables. At admission no variable was superior as a predictor of outcome. During resuscitation, significant changes were seen in mean arterial pressure, central venous pressure, oxygen delivery, systemic vascular resistance, total blood volume, right heart and ventricle end-diastolic volume, right ventricle ejection fraction, right and left stroke work index, intramucosal carbon dioxide pressure, gastric mucosal pH, mucosal-end tidal Pco2 gap, indocyanine green blood clearance, indocyanine green plasma clearance, and plasma disappearance rate. Multivariate analysis identified lactate, gastric mucosal pH, mucosal-end tidal Pco2 gap, mucosal-arterial Pco2 gap, indocyanine green plasma clearance, and plasma disappearance rate of dye as nondependent predictors of outcome. Patients who subsequently died had a significantly lower gastric mucosal pH, higher intramucosal carbon dioxide pressure and mucosal-end tidal Pco2 gap, and lower indocyanine green blood clearance, indocyanine green plasma clearance, plasma disappearance rate, and right ventricular end-diastolic volume index, of which gastric mucosal pH, mucosal-end tidal Pco2 gap, and indocyanine green blood clearance were the most important predictors of outcome.


CONCLUSIONS
Initial resuscitation of critically ill patients with shock does not require monitoring of regional variables. After stabilization, however, regional variables are the best predictors of outcome.
Poeze
Martijn
M
Department of Surgery, University Hospital Maastricht, The Netherlands.
Solberg
Barbara C J
BC
Greve
Jan Willem M
JW
Ramsay
Graham
G
D000368:Aged; D001794:Blood Pressure; D005260:Female; D006339:Heart Rate; D017052:Hospital Mortality; D006801:Humans; D007208:Indocyanine Green / Q000493:pharmacokinetics; D007362:Intensive Care Units; D008297:Male; D008657:Metabolic Clearance Rate; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012151:Resuscitation / Q000379:methods*; D018805:Sepsis / Q000503:physiopathology* / Q000628:therapy
D007208:Indocyanine Green