title: Tonometry revisited: perfusion-related, metabolic, and respiratory components of gastric mucosal acidosis in acute cardiorespiratory failure.
abstract: Mucosal pH (pHi) is influenced by local perfusion and metabolism (mucosal-arterial pCO2 gradient, DeltapCO2), systemic metabolic acidosis (arterial bicarbonate), and respiration (arterial pCO2). We determined these components of pHi and their relation to outcome during the first 24 h of intensive care. We studied 103 patients with acute respiratory or circulatory failure (age, 63+/-2 [mean+/-SEM]; Acute Physiology and Chronic Health Evaluation II score, 20+/-1; Sequential Organ Failure Assessment score, 8+/-0). pHi, and the effects of bicarbonate and arterial and mucosal pCO2 on pHi, were assessed at admission, 6, and 24 h. pHi was reduced (at admission, 7.27+/-0.01) due to low arterial bicarbonate and increased DeltapCO2. Low pHi (<7.32) at admission (n=58; mortality, 29% vs. 13% in those with pHi>or=7.32 at admission; P=0.061) was associated with an increased DeltapCO2 in 59% of patients (mortality, 47% vs. 4% for patients with low pHi and normal DeltapCO2; P=0.0003). An increased versus normal DeltapCO2, regardless of pHi, was associated with increased mortality at admission (51% vs. 5%; P<0.0001; n=39) and at 6 h (34% vs. 13%; P=0.016; n=45). A delayed normalization or persistently low pHi (n=47) or high DeltapCO2 (n=25) was associated with high mortality (low pHi [34%] vs. high DeltapCO2 [60%]; P=0.046). In nonsurvivors, hypocapnia increased pHi at baseline, 6, and 24 h (all P<or=0.001). In patients with initially normal pHi or DeltapCO2, outcome was not related to subsequent changes in pHi or DeltapCO2. Increased DeltapCO2 during early resuscitation suggests poor tissue perfusion and is associated with high mortality. Arterial bicarbonate contributes more to pHi than the DeltapCO2 but is not associated with mortality. Hyperventilation partly masks mucosal acidosis. Inadequate tissue perfusion may persist despite stable hemodynamics and contributes to poor outcome.
authors.affiliation: Department of Intensive Care Medicine, University Hospital Bern, University of Bern, Bern, Switzerland. stephan.jakob@insel.ch
authors.forename: Stephan M
authors.initials: SM
authors.lastname: Jakob
authors.forename: Ilkka
authors.initials: I
authors.lastname: Parviainen
authors.forename: Esko
authors.initials: E
authors.lastname: Ruokonen
authors.forename: Alexander
authors.initials: A
authors.lastname: Kogan
authors.forename: Jukka
authors.initials: J
authors.lastname: Takala
mesh_terms: D000138:Acidosis / Q000175:diagnosis* / Q000473:pathology; D001639:Bicarbonates / Q000737:chemistry / Q000378:metabolism; D002245:Carbon Dioxide / Q000737:chemistry; D005260:Female; D005753:Gastric Mucosa / Q000473:pathology*; D006333:Heart Failure / Q000175:diagnosis* / Q000473:pathology*; D006439:Hemodynamics; D006801:Humans; D006863:Hydrogen-Ion Concentration; D008297:Male; D008365:Manometry / Q000379:methods*; D010477:Perfusion; D012119:Respiration; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D001639:Bicarbonates; D002245:Carbon Dioxide