title: Continuous muscle tissue oxygenation in critically injured patients: a prospective observational study.
abstract: BACKGROUND
  Despite normalization of vital signs, critically injured patients may remain in a state of occult underresuscitation that sets the stage for sepsis, organ failure, and death. A continuous, sensitive, and accurate measure of resuscitation after injury remains elusive.
  
  
  METHODS
  In this pilot study, we evaluated the ability of two continuous measures of peripheral tissue oxygenation in their ability to detect hypoperfusion: the Licox polarographic tissue oxygen monitor (PmO2) and the InSpectra near-infrared spectrometer (StO2). We hypothesized that deltoid muscle tissue oxygenation measurements could detect patients in "occult shock" who are at increased risk for post-injury complications. The study was designed to (1) define values for PmO2 and StO2 in patients who by all standard measures appeared to be clinically resuscitated; (2) evaluate the relationship between PmO2, StO2 and other physiologic variables including mean arterial pressure (MAP), lactate and base deficit (BD); and (3) examine the relationship between early low tissue oxygen values and the subsequent development of infections and organ dysfunction. Licox probes were inserted into the deltoid muscle of critically injured patients after initial surgical and radiologic interventions, and transcutaneous StO2 monitors were applied over the same muscle bed. PmO2, StO2, and standard physiologic data were collected continuously using a multimodal bioinformatics system.
  
  
  RESULTS
  Twenty-eight critically injured patients were enrolled in this study at admission to the intensive care unit (ICU). For patients who appeared to be well resuscitated (defined as MAP > or = 70 mm Hg, heart rate [HR] < or = 110 bpm, BD > or = -2, and partial pressure of arterial oxygen (PaO2) = 80 and 150 mm Hg), the mean PmO2 was 34 +/- 11 mm Hg and StO2 was 63 +/- 27%. There was a strong relationship between PmO2 and BD (p < 0.001) but no significant relationship between StO2 and BD. The relationship between PmO2 and StO2 was weak but statistically significant. Early low values of both PmO2 and StO2 identified patients at risk for infectious complications or multiple organ failure (MOF). In patients who were well resuscitated by standard continuous parameters (HR and MAP), low PmO2 during the first 24 hours after admission (PmO2 < or = 25 for at least 2 hours) was strongly associated with the development of infectious complications (Odds Ratio = 16.5, 95% CI 1.49 to 183, p = 0.02).
  
  
  CONCLUSIONS
  PmO2 is a responsive, reliable and continuous monitor of changes in base deficit. Initial low values for either PmO2 or StO2 were associated with post-injury complications. PmO2 monitoring may be useful in identifying patients in the state of occult underresuscitation who remain at risk for developing infection and MOF.
authors.affiliation: Department of Surgery, University of California, San Francisco and the San Francisco Injury Center for Research and Prevention, San Francisco, California, USA.
authors.forename: Danagra G
authors.initials: DG
authors.lastname: Ikossi
authors.forename: M Margaret
authors.initials: MM
authors.lastname: Knudson
authors.forename: Diane J
authors.initials: DJ
authors.lastname: Morabito
authors.forename: Mitchell J
authors.initials: MJ
authors.lastname: Cohen
authors.forename: Jennifer J
authors.initials: JJ
authors.lastname: Wan
authors.forename: Linda
authors.initials: L
authors.lastname: Khaw
authors.forename: Campbell J
authors.initials: CJ
authors.lastname: Stewart
authors.forename: Claude
authors.initials: C
authors.lastname: Hemphill
authors.forename: Geoff T
authors.initials: GT
authors.lastname: Manley
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000295:instrumentation; D009102:Multiple Organ Failure / Q000209:etiology; D018482:Muscle, Skeletal / Q000000981:diagnostic imaging / Q000378:metabolism*; D010101:Oxygen Consumption / Q000502:physiology*; D011048:Polarography; D011446:Prospective Studies; D012151:Resuscitation / Q000295:instrumentation / Q000379:methods*; D014463:Ultrasonography; D014947:Wounds and Injuries / Q000378:metabolism / Q000401:mortality / Q000628:therapy*