The 2003 Carl A. Moyer Award - Real-time metabolic monitors, ischemia-reperfusion, titration endpoints, and ultraprecise burn resuscitation

Real-time metabolic monitoring of varied vascular beds provides the raw data necessary to conduct ultraprecise burn shock resuscitation based on second-by-second assessment of regional tissue perfusion. It also illustrates shortcomings of current clinical practices. Arterial base deficit was continuously monitored during 11 clinical resuscitations of patients suffering burn shock using a Paratrend monitor. Separately, in a 30% TBSA rat burn model (N = 70), three Paratrend monitors simultaneously recorded arterial blood gas and tissue pCO(2), of the burn wound and colonic mucosa during resuscitation at 0, 2, 4, 6, and 8 ml/kg/ %TBSA. Paratrend data were analyzed in conjunction with previously reported laser Doppler images of actual burn wound capillary perfusion. With current clinical therapy, continuous monitoring of arterial base deficit revealed repetitive cycles of resolution/worsening/ resolution during burn shock resuscitation. In the rat model, tissue pCO(2) in both burn wounds and splanchnic circulation differed depending on the rate of fluid resuscitation (P <.01 between sham and 0 ml/kg/%TBSA and between 2 ml/kg/%TBSA and 4 ml/kg/ %TBSA). Burn wound pCO(2) values correlated well with laser Doppler determination of actual capillary perfusion (p = -.48, P <.01). The following conclusions were reached: 1) Gratuitous and repetitive ischemia-reperfusion-ischemia cycles plague current clinical therapy as demonstrated by numerous "false starts" in the resolution of arterial base deficit; 2) in a rat model, real-time monitoring of burn wound and splanchnic pCO(2) demonstrate a dose-response relationship with rate of fluid administration; and 3) burn wound and splanchnic pCO(2) are highly correlated with direct measurement of burn wound capillary perfusion by laser Doppler imager. Either technique can serve as a resuscitation endpoint for real-time feedback-controlled ultraprecise resuscitation.