SUMMARY INTRODUCTION.This prospective non-interventional study intended to assess the prognostic value of gastric intramucosal acidosis in patients with severe trauma admitted to a medical/surgical ICU. METHODS. Gastric tonometer catheters were introduced to measure air PCO 2 level (Tonocap device) in forty consecutive critically ill trauma patients. Gastric intramucosal pH, air PCO 2 gradient, lactate and acid-base parameters were measured at admission and at 6, 12 and 24 h thereafter. RESULTS. The median age, mean APACHE II and SOFA scores were higher in nonsurvivors than in survivors (p<0.05). There were significant differences in the PCO 2 gradient between survivors and nonsurvivors at 12 and 24 hours (10±7 vs. 24±19 mmHg, 13±16 vs. 29±25 mmHg; p<0.05). Gastric intramucosal pH values were lower in nonsurvivors than in survivors, on admission and after 12 or 24 hours (p<0.05). Arterial pH and bicarbonate were lower, lactate concentration higher, and base excess more negative in nonsurvivors. Prediction of outcome (mortality and MODS) at 24 hours of ICU assessed by their ROC curves was similar (p=NS). At 24 hours, air PCO 2 gradient > 18 mmHg carried a relative risk of 4.6 for death, slightly higher than a HCO 3 <20 mEq/L (RR=4.29) or base excess of <-2 mmol/L (RR=3.65). CONCLUSION. Bicarbonate, base deficit, lactate, gastric intramucosal pH and PCO 2 gradient discriminate survivors from nonsurvivors of major trauma. A critical air PCO 2 gradient carried the greatest relative risk for death at 24 hours of ICU. Inadequate regional blood flow as detected by a critical PCO 2 gradient seems to contribute to morbidity and mortality of severe trauma patients.
Purpose: To describe the epidemiology of the acute respiratory distress syndrome (ARDS) in a Brazilian ICU. Methods: This prospective observational, non-interventional study, included all consecutive patients with ARDS criteria [1] admitted in the ICU of a Brazilian tertiary hospital, between January 1997 and September 2001. Were collected in a prospective fashion the following variables: age, gender, APACHE II score at ICU admission and at ARDS diagnosis, cause of ARDS, presence of AIDS, cancer and immunosuppression, occurrence of barotrauma, performance of traqueostomy, mortality, duration of mechanical ventilation (MV), length of stay (LOS) in ICU and in hospital. The lung injury score (LIS) [2] was used to quantify the degree of pulmonary injury in the first week of ARDS. Results: There was 2182 patients (P) admitted in ICU during the study period, of whom 141 (6.46%) had ARDS criteria. Seventy-six (54%) were men, the mean age was 46 ± 18 years, APACHE II 18 ± 7 and 19 ± 7 at admission and at ARDS diagnosis, respectively. Septic shock accounted for 42% (60 P) of the ARDS causes, sepsis 22% (31 P), diffuse pulmonary infection 16% (23 P), aspiration pneumonia 11% (15 P), non-septic shock 5% (7 P) and others 4% (5 P). Ten percent (14 P) had AIDS, 30% (43 P) cancer and 25% (36 P) immunosuppression. All patients were mechanically ventilated with Tidal Volume between 4 and 8 ml/kg. Only 3.5% (5 P) had barotrauma and 10% (14 P) performed traqueostomy. Mortality rate was 79% in the ICU. The patients required 12 ± 10 days on MV, ranging from 1 to 55 days. The LOS in ICU and hospital was 14 ± 13 (1-69) days and 28 ± 32 (1-325) days, respectively. There was a time delay of 3.7 ± 4.5 days between admission in ICU and the onset of ARDS. The Murray score (mean ± SD) was 3.2 ± 0.4, 3 ± 0.5, 3 ± 0.5, 2.9 ± 0.6, 2.8 ± 0.7, 2.7 ± 0.7 and 2.6 ± 0.8 in the first 7 days, respectively. Conclusions: ARDS in our hospital has a similar incidence of reports in the USA and Europe. There was a higher mortality, which could be explained by a high incidence of infection causes of ARDS, mainly septic shock, and elevated combined occurrence of AIDS, cancer and immunosuppression, along the degree of LIS. The incidence of barotrauma was low, as a consequence of the current mechanical ventilation strategies.
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