Dunne James R, Tracy J Kathleen, Scalea Thomas M, Napolitano Lena M
University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, Maryland 21201, USA.
J Trauma. 2005 May;58(5):959-66. doi: 10.1097/01.ta.0000158508.84009.49.
Abnormal blood lactate and base deficit (BD) reflect hypoperfusion and have been documented to predict outcome in trauma. Alcohol and drug use may also induce metabolic acidosis in trauma victims, potentially diminishing the predictive accuracy of lactate and BD. We, therefore, sought to examine the effect of alcohol and drug use on the predictive accuracy of admission blood lactate and BD in trauma.
Prospective data were collected on 15,179 patients admitted to the R Adams Cowley Shock Trauma Center over a 3-year period from 1998 to 2000. Patients were stratified by age, gender, race, injury severity score (ISS), Glasgow coma score (GCS), alcohol concentration and illicit drug use. Multiple regression analyses were used to assess admission blood lactate and BD as independent risk factors for mortality, intensive care unit (ICU) admission, and ICU and hospital length of stay (LOS) controlling for alcohol and drug use [cocaine, phencyclidine and methamphetamines] by measured serum concentrations.
The mean age of the study cohort was 37 +/- 19 years, mean ISS was 9 +/- 10, mean GCS 14.1 +/- 2.7, 71% were male and 77% sustained blunt trauma. Alcohol testing was completed in 13,102 of 15,179 (86.3%) of patients. Alcohol screen was positive in 27% (n = 3536) of the total cohort tested (n = 13,102) with a mean blood alcohol concentration of 141 +/- 95 mg/dL; 7% (n = 992) had positive drug screens. Increasing injury severity was associated with significantly increased admission blood lactate and BD (p < 0.001). Patients with positive alcohol and drug screens had significantly increased admission blood lactate, BD and injury severity compared with patients with negative alcohol and drug screens (p < 0.01). Patients with positive alcohol and drug screens had a significant increase in admission to the ICU (p < 0.05), but no significant increase in mortality, ICU or hospital LOS compared with patients with negative screens. Multiple logistic and linear regression analyses confirmed admission lactate and BD as significant independent predictors of mortality, ICU and hospital LOS (p < 0.01). These results were unchanged after controlling for alcohol and drug use as covariates in the logistic and linear regression analyses.
Alcohol and drug use are common in trauma, but do not impair the predictive accuracy of admission lactate and BD in trauma outcome. Admission lactate and BD are therefore confirmed as significant independent predictors of trauma outcome in patients with acute alcohol and drug use in this largest clinical study to date.
血液乳酸和碱缺失异常反映了灌注不足，并且已被证明可预测创伤患者的预后。酒精和药物使用也可能在创伤患者中诱发代谢性酸中毒，这可能会降低乳酸和碱缺失的预测准确性。因此，我们试图研究酒精和药物使用对创伤患者入院时血液乳酸和碱缺失预测准确性的影响。
收集了1998年至2000年3年间入住R·亚当斯·考利休克创伤中心的15179例患者的前瞻性数据。患者按年龄、性别、种族、损伤严重程度评分（ISS）、格拉斯哥昏迷评分（GCS）、酒精浓度和非法药物使用情况进行分层。多元回归分析用于评估入院时血液乳酸和碱缺失作为死亡率、重症监护病房（ICU）入住率以及ICU和住院时间（LOS）的独立危险因素，并通过测量血清浓度来控制酒精和药物使用情况[可卡因、苯环己哌啶和甲基苯丙胺]。
研究队列的平均年龄为37±19岁，平均ISS为9±10，平均GCS为14.1±2.7，71%为男性，77%为钝性创伤。15179例患者中有13102例（86.3%）完成了酒精检测。在接受检测的全部队列（n = 13102）中，27%（n = 3536）的酒精筛查呈阳性，平均血液酒精浓度为141±95mg/dL；7%（n = 992）的药物筛查呈阳性。损伤严重程度增加与入院时血液乳酸和碱缺失显著增加相关（p < 0.001）。与酒精和药物筛查阴性的患者相比，酒精和药物筛查阳性的患者入院时血液乳酸、碱缺失和损伤严重程度显著增加（p < 0.01）。与筛查阴性的患者相比，酒精和药物筛查阳性的患者入住ICU的比例显著增加（p < 0.05），但死亡率、ICU或住院时间无显著增加。多元逻辑回归和线性回归分析证实入院乳酸和碱缺失是死亡率、ICU和住院时间的重要独立预测因素（p < 0.01）。在逻辑回归和线性回归分析中，将酒精和药物使用作为协变量进行控制后，这些结果没有改变。
酒精和药物使用在创伤患者中很常见，但不会损害入院乳酸和碱缺失对创伤预后的预测准确性。因此，在这项迄今为止最大规模的临床研究中，入院乳酸和碱缺失被确认为急性酒精和药物使用患者创伤预后的重要独立预测因素。
