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Zsolt Balogh, MD; Bruce A. McKinley, PhD; Christine S. Cocanour, MD; Rosemary A. Kozar, MD, PhD; Alicia Valdivia, RN; R. Matthew Sailors, PhD; Frederick A. Moore, MD

Arch Surg. 2003;138:637-643.

Hypothesis  Normal resuscitation (oxygen delivery index [DO₂I] 500 mL/min per square meter), compared with supranormal trauma resuscitation (DO₂I 600 mL/min per square meter), requires less crystalloid volume, thus decreasing the incidence of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS).

Design  Retrospective analysis of a prospective database.

Setting  Twenty-bed intensive care unit (ICU) in a regional level I trauma center.

Patients  Patients with major trauma (injury severity score >15, initial base deficit 6 mEq/L, or need for 6 units of packed red blood cells in the first 12 hours) or age 65 years or older with any 2 of the previous criteria.

Interventions  Shock/trauma resuscitation protocol: pulmonary artery catheter, gastric tonometry, urinary bladder pressure measurements, lactated Ringer infusion, packed red blood cell transfusion, and moderate inotrope support, as needed, in that sequence, to attain and maintain a DO₂I greater than or equal to 600 mL/min per m² (16 months, ending January 1, 2001, n = 85) or a DO₂I greater than or equal to 500 mL/min per square meter (16 months, starting January 1, 2001, n = 71) for the first 24 hours in the ICU.

Main Outcome Measures:  Lactated Ringer infusion volume (liters) at ICU admission, gastric partial carbon dioxide minus end-tidal carbon dioxide(GAP_CO2), IAH (urinary bladder pressure measurements >20 mm Hg), ACS (urinary bladder pressure measurements >25 mm Hg with organ dysfunction), multiple organ failure, and mortality.

Results  Demographics, injury severity, and shock severity parameters were similar in both groups. The supranormal resuscitation group required more lactated Ringer infusion volume in the first 24 hours in the ICU (mean ± SD, 13 ± 2 vs 7 ± 1 L; P<.05) and had higher GAP_CO2 (16 ± 2 vs 7 ± 1 mm Hg; P<.05). In the supranormal group, IAH (42% vs 20%; P<.05) and ACS (16% vs 8%; P<.05) were more frequent. The conventional trauma outcomes, such as multiple organ failure (22% vs 9%; P<.05) and mortality (27% vs 11%; P<.05) were less favorable in the supranormal resuscitation group.

Conclusion  Supranormal resuscitation, compared with normal resuscitation, was associated with more lactated Ringer infusion, decreased intestinal perfusion (higher GAP_CO2), and an increased incidence of IAH, ACS, multiple organ failure, and death.

From the Departments of Surgery and Shock Trauma, Intensive Care Unit, Memorial Hermann Hospital, University of Texas–Houston Medical School, Houston.

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