Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
Shock. 2012 Aug;38(3):249-54. doi: 10.1097/SHK.0b013e3182613e33.
Clinical deterioration among hemodynamically stable sepsis patients occurs frequently, and patients with intermediate lactate levels (between 2.0 and 4.0 mmol/L) are particularly at risk for mortality. The aim of this study was to identify factors for predicting early deterioration in sepsis patients with intermediate levels of serum lactate. A retrospective cohort study of adult sepsis patients with lactate levels between 2.0 and 4.0 mmol/L was conducted in the emergency department of a tertiary care hospital between August 2008 and July 2010. The primary outcome was progression to sepsis-induced shock defined as persistent hypotension despite initial fluid challenge or a blood lactate concentration 4 mmol/L or greater within 72 hours of emergency department arrival. Among the 474 patients enrolled in the study, there were 108 cases of sepsis-induced tissue hypoperfusion (22.7%) and 48 deaths (10.1%). In a multivariate regression analysis, independent predictors for progression were hyperthermia, neutropenia, band neutrophils appearance, hyponatremia, blood urea nitrogen level, serum lactate level, and organ failure including respiratory, cardiovascular, and central nervous system. Initial Sequential Organ Failure Assessment score was also associated with progression. In patients with a Sequential Organ Failure Assessment score of 5 or greater, the predicted rate of progression to tissue hypoperfusion was 38.9%. Our study demonstrates potential risk factors, including organ failure, for progression to sepsis-induced tissue hypoperfusion in patients with intermediate levels of serum lactate. We suggest that an early aggressive treatment strategy is needed in patients with these risk factors.
血流动力学稳定的脓毒症患者经常发生临床恶化，而血清乳酸水平在 2.0 至 4.0mmol/L 之间的患者尤其存在死亡风险。本研究旨在确定预测血清乳酸水平在 2.0 至 4.0mmol/L 之间的脓毒症患者早期恶化的因素。这是一项回顾性队列研究，纳入了 2008 年 8 月至 2010 年 7 月在三级护理医院急诊科就诊的乳酸水平在 2.0 至 4.0mmol/L 之间的成年脓毒症患者。主要结局是进展为脓毒症性休克，定义为初始液体复苏后仍持续低血压，或急诊科就诊 72 小时内血乳酸浓度≥4mmol/L。在纳入的 474 例患者中，有 108 例发生脓毒症性组织低灌注（22.7%）和 48 例死亡（10.1%）。多变量回归分析显示，独立的进展预测因素包括发热、中性粒细胞减少症、出现幼稚粒细胞、低钠血症、血尿素氮水平、血清乳酸水平以及包括呼吸、心血管和中枢神经系统在内的器官衰竭。初始序贯器官衰竭评估评分也与进展相关。在序贯器官衰竭评估评分≥5 分的患者中，进展为组织低灌注的预测率为 38.9%。本研究表明，包括器官衰竭在内的潜在危险因素与血清乳酸水平在中间水平的患者进展为脓毒症性组织低灌注相关。我们建议，对于有这些危险因素的患者，需要采取早期积极的治疗策略。
