Endpoints of resuscitation of critically injured patients

Normal or supranormal? A prospective randomized trial

George C. Velmahos, Demetrios Demetriades, William C. Shoemaker, Linda S. Chan, Raymond Tatevossian, C. C J Wo, Pantelis Vassiliu, Edward E. Cornwell, James A. Murray, Bradley Roth, Howard Belzberg, Juan A. Asensio, Thomas V. Berne

Research output: Contribution to journalArticle

157 Citations (Scopus)

Abstract

Objective: To evaluate the effect of early optimization in the survival of severely injured patients. Summary Background Data: It is unclear whether supranormal ('optimal') hemodynamic values should serve as endpoints of resuscitation or simply as markers of the physiologic reserve of critically injured patients. The failure of optimization to produce improved survival in some randomized controlled trials may be associated with delays in starting the attempt to reach optimal goals. There are limited controlled data on trauma patients. Methods: Seventy-five consecutive severely injured patients with shock resulting from bleeding and without major intracranial or spinal cord trauma were randomized to resuscitation, starting immediately after admission, to either normal values of systolic blood pressure, urine output, base deficit, hemoglobin, and cardiac index (control group, 35 patients) or optimal values (cardiac index >4.5 L/min/m2, ratio of transcutaneous oxygen tension to fractional inspired oxygen >200, oxygen delivery index >600 mL/min/m2, and oxygen consumption index >170 mL/min/m2; optimal group, 40 patients). Initial cardiac output monitoring was done noninvasively by bioimpedance and, subsequently, invasively by thermodilution. Crystalloids, colloids, blood, inotropes, and vasopressors were used by predetermined algorithms. Results: Optimal values were reached intentionally by 70% of the optimal patients and spontaneously by 40% of the control patients. There was no difference in rates of death (15% optimal vs. 11% control), organ failure, sepsis, or the length of intensive care unit or hospital stay between the two groups. Patients from both groups who achieved optimal values had better outcomes than patients who did not. The death rate was 0% among patients who achieved optimal values compared with 30% among patients who did not. Age younger than 40 years was the only independent predictive factor of the ability to reach optimal values. Conclusions: Severely injured patients who can achieve optimal hemodynamic values are more likely to survive than those who cannot, regardless of the resuscitation technique. In this study, attempts at early optimization did not improve the outcome of the examined subgroup of severely injured patients.

Original languageEnglish
Pages (from-to)409-418
Number of pages10
JournalAnnals of Surgery
Volume232
Issue number3
DOIs
StatePublished - 2000
Externally publishedYes

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Resuscitation
Oxygen
Hemodynamics
Blood Pressure
Thermodilution
Survival
Mortality
Colloids
Spinal Cord Injuries
Oxygen Consumption
Cardiac Output
Intensive Care Units
Shock
Length of Stay
Sepsis
Reference Values
Hemoglobins
Randomized Controlled Trials
Urine
Hemorrhage

All Science Journal Classification (ASJC) codes

  • Surgery

Cite this

Velmahos, G. C., Demetriades, D., Shoemaker, W. C., Chan, L. S., Tatevossian, R., Wo, C. C. J., ... Berne, T. V. (2000). Endpoints of resuscitation of critically injured patients: Normal or supranormal? A prospective randomized trial. Annals of Surgery, 232(3), 409-418. https://doi.org/10.1097/00000658-200009000-00013

Endpoints of resuscitation of critically injured patients : Normal or supranormal? A prospective randomized trial. / Velmahos, George C.; Demetriades, Demetrios; Shoemaker, William C.; Chan, Linda S.; Tatevossian, Raymond; Wo, C. C J; Vassiliu, Pantelis; Cornwell, Edward E.; Murray, James A.; Roth, Bradley; Belzberg, Howard; Asensio, Juan A.; Berne, Thomas V.

In: Annals of Surgery, Vol. 232, No. 3, 2000, p. 409-418.

Research output: Contribution to journalArticle

Velmahos, GC, Demetriades, D, Shoemaker, WC, Chan, LS, Tatevossian, R, Wo, CCJ, Vassiliu, P, Cornwell, EE, Murray, JA, Roth, B, Belzberg, H, Asensio, JA & Berne, TV 2000, 'Endpoints of resuscitation of critically injured patients: Normal or supranormal? A prospective randomized trial', Annals of Surgery, vol. 232, no. 3, pp. 409-418. https://doi.org/10.1097/00000658-200009000-00013
Velmahos, George C. ; Demetriades, Demetrios ; Shoemaker, William C. ; Chan, Linda S. ; Tatevossian, Raymond ; Wo, C. C J ; Vassiliu, Pantelis ; Cornwell, Edward E. ; Murray, James A. ; Roth, Bradley ; Belzberg, Howard ; Asensio, Juan A. ; Berne, Thomas V. / Endpoints of resuscitation of critically injured patients : Normal or supranormal? A prospective randomized trial. In: Annals of Surgery. 2000 ; Vol. 232, No. 3. pp. 409-418.
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abstract = "Objective: To evaluate the effect of early optimization in the survival of severely injured patients. Summary Background Data: It is unclear whether supranormal ('optimal') hemodynamic values should serve as endpoints of resuscitation or simply as markers of the physiologic reserve of critically injured patients. The failure of optimization to produce improved survival in some randomized controlled trials may be associated with delays in starting the attempt to reach optimal goals. There are limited controlled data on trauma patients. Methods: Seventy-five consecutive severely injured patients with shock resulting from bleeding and without major intracranial or spinal cord trauma were randomized to resuscitation, starting immediately after admission, to either normal values of systolic blood pressure, urine output, base deficit, hemoglobin, and cardiac index (control group, 35 patients) or optimal values (cardiac index >4.5 L/min/m2, ratio of transcutaneous oxygen tension to fractional inspired oxygen >200, oxygen delivery index >600 mL/min/m2, and oxygen consumption index >170 mL/min/m2; optimal group, 40 patients). Initial cardiac output monitoring was done noninvasively by bioimpedance and, subsequently, invasively by thermodilution. Crystalloids, colloids, blood, inotropes, and vasopressors were used by predetermined algorithms. Results: Optimal values were reached intentionally by 70{\%} of the optimal patients and spontaneously by 40{\%} of the control patients. There was no difference in rates of death (15{\%} optimal vs. 11{\%} control), organ failure, sepsis, or the length of intensive care unit or hospital stay between the two groups. Patients from both groups who achieved optimal values had better outcomes than patients who did not. The death rate was 0{\%} among patients who achieved optimal values compared with 30{\%} among patients who did not. Age younger than 40 years was the only independent predictive factor of the ability to reach optimal values. Conclusions: Severely injured patients who can achieve optimal hemodynamic values are more likely to survive than those who cannot, regardless of the resuscitation technique. In this study, attempts at early optimization did not improve the outcome of the examined subgroup of severely injured patients.",
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T2 - Normal or supranormal? A prospective randomized trial

AU - Velmahos, George C.

AU - Demetriades, Demetrios

AU - Shoemaker, William C.

AU - Chan, Linda S.

AU - Tatevossian, Raymond

AU - Wo, C. C J

AU - Vassiliu, Pantelis

AU - Cornwell, Edward E.

AU - Murray, James A.

AU - Roth, Bradley

AU - Belzberg, Howard

AU - Asensio, Juan A.

AU - Berne, Thomas V.

PY - 2000

Y1 - 2000

N2 - Objective: To evaluate the effect of early optimization in the survival of severely injured patients. Summary Background Data: It is unclear whether supranormal ('optimal') hemodynamic values should serve as endpoints of resuscitation or simply as markers of the physiologic reserve of critically injured patients. The failure of optimization to produce improved survival in some randomized controlled trials may be associated with delays in starting the attempt to reach optimal goals. There are limited controlled data on trauma patients. Methods: Seventy-five consecutive severely injured patients with shock resulting from bleeding and without major intracranial or spinal cord trauma were randomized to resuscitation, starting immediately after admission, to either normal values of systolic blood pressure, urine output, base deficit, hemoglobin, and cardiac index (control group, 35 patients) or optimal values (cardiac index >4.5 L/min/m2, ratio of transcutaneous oxygen tension to fractional inspired oxygen >200, oxygen delivery index >600 mL/min/m2, and oxygen consumption index >170 mL/min/m2; optimal group, 40 patients). Initial cardiac output monitoring was done noninvasively by bioimpedance and, subsequently, invasively by thermodilution. Crystalloids, colloids, blood, inotropes, and vasopressors were used by predetermined algorithms. Results: Optimal values were reached intentionally by 70% of the optimal patients and spontaneously by 40% of the control patients. There was no difference in rates of death (15% optimal vs. 11% control), organ failure, sepsis, or the length of intensive care unit or hospital stay between the two groups. Patients from both groups who achieved optimal values had better outcomes than patients who did not. The death rate was 0% among patients who achieved optimal values compared with 30% among patients who did not. Age younger than 40 years was the only independent predictive factor of the ability to reach optimal values. Conclusions: Severely injured patients who can achieve optimal hemodynamic values are more likely to survive than those who cannot, regardless of the resuscitation technique. In this study, attempts at early optimization did not improve the outcome of the examined subgroup of severely injured patients.

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