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Background: The base deficit, an important indicator of physiologic derangement after severe injury in adults, has not been specifically examined in the pediatric trauma population. The purpose of this study was to assess the ability of the admission base deficit to predict injury severity and outcome in the pediatric trauma population., Methods: The study group included all patients in the National Trauma Data Bank over a 2-year period aged 0 to 12 years with a base deficit (0 to -30 mEq/L) recorded from the emergency department. Age, presence of a severe closed head injury, and base deficit were analyzed with respect to mortality and other indicators of injury severity., Results: A total of 515 patients constituted the study group. Base deficit less than -4 mEq/L (p < 0.001) and the presence of a closed head injury (odds ratio, 3.8; p < 0.05) were predictors of mortality. For the group, an admission base deficit of -8 mEq/L corresponded to a probability of mortality of 25%. Significant correlations were found between base deficit and emergency department systolic blood pressure, Injury Severity Score, and Revised Trauma Score. There was no relationship between age and mortality., Conclusion: In injured children, the admission base deficit reflects injury severity and predicts mortality. The probability of mortality increases precipitously in children with a base deficit less than -8 mEq/L, and should alert the clinician to the presence of potentially lethal injuries or uncompensated shock.

Background: While the right ventricular end-diastolic volume index (RVEDVI) has been shown to be a better indicator of preload than cardiac filling pressures, optimal values during resuscitation from trauma are unknown. This study examines right ventricular stiffness as a guide to optimal values of RVEDVI., Methods: Prospective study of 19 critically injured patients monitored with a volumetric pulmonary artery catheter during resuscitation. Per resuscitation protocol, the target RVEDVI was > or = 120 mL/m2. Sequential fluid boluses of 500 to 1000 mL were administered to obtain at least four values of RVEDVI and right ventricular end-diastolic pressure (estimated by central venous pressure [CVP]). For each patient, nonlinear regression was used to construct the ventricular compliance curve based on the equation, CVP = aek(RVEDVI), where k is the coefficient of chamber stiffness., Results: Overall, the derived compliance curves had excellent fit with the theoretical equation (mean R2, 0.95 +/- 0.04). Mean k was 0.043 +/- 0.012 (range, 0.029-0.067). For each patient, mean RVEDVI during resuscitation was significantly correlated with k (R2 = 0.75, p < 10-5) indicating that chamber stiffness, measured during initial fluid administration, may be used to determine RVEDVI during the ensuing resuscitation., Conclusion: In critically injured patients, bedside assessment of right ventricular compliance is possible and may help determine optimal values of RVEDVI during resuscitation.

Objective: Maintaining left ventricular power output (LVP) > 320 mm Hg x L/min/m2 during resuscitation has been retrospectively associated with faster resolution of acidosis and survival after posttraumatic shock. The purpose of this prospective study was to evaluate the effects of maintaining LVP above this threshold during resuscitation on base deficit clearance, organ failure, and survival., Methods: This was a study of a consecutive series of critically injured patients (PWR) monitored with a pulmonary artery catheter during initial resuscitation. LVP, calculated as cardiac index-(mean arterial pressure-central venous pressure), was maintained >320 mm Hg x L/min/m2 via a predefined protocol by using ventricular pressure-volume diagrams. Outcome was assessed by base deficit clearance (<6 mEq/L) in <24 hours, lowest base deficit in the first 24 hours after admission (24-hr base deficit), organ dysfunctions/patient, and survival. Results were compared with 39 control patients (OXY) with identical enrollment criteria from a previous prospective study who were resuscitated based on oxygen transport criteria., Results: Twenty patients were studied over a 6-month period. Mean LVP during resuscitation in the PWR group was 360 +/- 100 mm Hg x L/min/m2. Admission base deficit was similar between the two groups (PWR 11 +/- 4.2 vs. OXY 11 +/- 5.8 mEq/L;p = 0.66). More PWR patients cleared base deficit in < 24 hours than OXY patients (16 of 20 vs. 17 of 39, p = 0.009, Fisher's exact test), and the PWR patients had a significantly lower 24-hr base deficit (3.9 +/- 3.7 vs. 7.1 +/- 4.6 mEq/L, p = 0.01). Organ dysfunction rate was lower in the PWR group (2.1 +/- 1.5 vs. 3.2 +/- 1.4 organ dysfunctions/patient, p = 0.007). Survival in the PWR group was 15 of 20, versus 21 of 39 in the OXY group (p = 0.10)., Conclusion: Prospectively maintaining LVP above 320 mm Hg x L/min/m2 during resuscitation is an achievable goal. It is associated with improved base deficit clearance and a lower rate of organ dysfunction after resuscitation from traumatic shock.

Background: The gastric intramucosal pH (pHi) and gastric mucosal-arterial CO2 gap (GAP) estimate visceral perfusion and predict outcome. Threshold values of these variables for use during resuscitation, however, remain poorly defined. The purpose of this study was to develop clinically derived cutoffs for both pHi and GAP for predicting death and multiple organ failure (MOF) in trauma patients., Methods: This was a cohort study of 114 consecutive trauma patients who had pHi determined at 24 hours after intensive care unit admission. The corresponding GAP for each of these values of pHi was obtained through chart review. Receiver operating characteristic curves were constructed for both pHi and GAP with respect to death and MOF. These curves were used to determine the value of each variable that maximized the sum of sensitivity and specificity in predicting outcome. chi2 tests and odds ratios were used to determine if significant differences in outcome occurred above and below these cutoff values., Results: Of 114 patients who had pHi determined at 24 hours after admission, 108 had corresponding GAP values available. The values of pHi and GAP that maximized sensitivity and specificity were 7.25 and 18 mm Hg, respectively. The odds ratio for pHi versus death was 4.6 and for pHi versus MOF was 4.3. The odds ratios for GAP versus death and MOF were 2.9 and 3.3, respectively., Conclusion: In trauma patients, the ability to predict death and MOF is maximized at values of pHi less than 7.25 and GAP greater than 18 mm Hg. These values represent clinically derived cutoffs that should be useful for evaluating the adequacy of intestinal perfusion during resuscitation.