Thomas-Rueddel Daniel O, Poidinger Bernhard, Weiss Manfred, Bach Friedhelm, Dey Karin, Häberle Helene, Kaisers Udo, Rüddel Hendrik, Schädler Dirk, Scheer Christian, Schreiber Torsten, Schürholz Tobias, Simon Philipp, Sommerer Armin, Schwarzkopf Daniel, Weyland Andreas, Wöbker Gabriele, Reinhart Konrad, Bloos Frank
Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany; The Integrated Research and Treatment Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.
Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.
J Crit Care. 2015 Apr;30(2):439.e1-6. doi: 10.1016/j.jcrc.2014.10.027. Epub 2014 Oct 30.
Current guidelines and most trials do not consider elevated lactate (Lac) serum concentrations when grading sepsis severity. We therefore assessed the association of different types of circulatory dysfunction regarding presence of hyperlactatemia and need for vasopressor support with clinical presentation and outcome of sepsis.
In a secondary analysis of a prospective observational multicenter cohort study, 988 patients with severe sepsis were investigated regarding vasopressor support, Lac levels, and outcome.
Twenty-eight-day mortality regarding shock or hyperlactatemia was as follows: hyperlactatemia more than 2.5 mmol/L and septic shock (tissue dysoxic shock): 451 patients with a mortality of 44.8%; hyperlactatemia without vasopressor need (cryptic shock): 72 patients, mortality 35.3%; no hyperlactatemia with vasopressor need (vasoplegic shock): 331 patients, mortality 27.7%; and absence of hyperlactemia or overt shock (severe sepsis): 134 patients, mortality 14.2% (P < .001). These groups showed differences in source and origin of infection. The influence of hyperlactatemia on 28-day mortality (P < .001) (odds ratio 3.0, 95% confidence interval 2.1-4.1 for Lac >4 mmol/L) was independent of vasopressor support (P < .001) (odds ratio 2.0, 95% confidence interval 1.3-3.0 for norepinephrine >0.1 μg/kg per minute) in logistic regression.
Hyperlactatemia increases risk of death independent of vasopressor need resulting in different phenotypes within the classic categories of severe sepsis and septic shock.
目前的指南和大多数试验在对脓毒症严重程度进行分级时未考虑血清乳酸（Lac）浓度升高的情况。因此，我们评估了不同类型循环功能障碍与高乳酸血症的存在以及血管加压药支持需求之间的关联，及其与脓毒症临床表现和预后的关系。
在一项前瞻性观察性多中心队列研究的二次分析中，对988例严重脓毒症患者的血管加压药支持、Lac水平和预后进行了调查。
与休克或高乳酸血症相关的28天死亡率如下：乳酸水平高于2.5 mmol/L且伴有脓毒性休克（组织缺氧性休克）：451例患者，死亡率为44.8%；无血管加压药需求的高乳酸血症（隐匿性休克）：72例患者，死亡率为35.3%；有血管加压药需求但无高乳酸血症（血管麻痹性休克）：331例患者，死亡率为27.7%；无高乳酸血症或明显休克（严重脓毒症）：134例患者，死亡率为14.2%（P <.001）。这些组在感染源和起源方面存在差异。在逻辑回归中，高乳酸血症对28天死亡率的影响（P <.001）（乳酸>4 mmol/L时，比值比为3.0，95%置信区间为2.1 - 4.1）独立于血管加压药支持（P <.001）（去甲肾上腺素>0.1 μg/kg每分钟时，比值比为2.0，95%置信区间为1.3 - 3.0）。
高乳酸血症增加死亡风险，且独立于血管加压药需求，在严重脓毒症和脓毒性休克的经典分类中导致不同的表型。
