Houwink Aletta P I, Rijkenberg Saskia, Bosman Rob J, van der Voort Peter H J
Department of Intensive Care, OLVG, Amsterdam, The Netherlands.
Department of Intensive Care, AvL hospital, Amsterdam, The Netherlands.
Crit Care. 2016 Mar 12;20:56. doi: 10.1186/s13054-016-1243-3.
During resuscitation in severe sepsis and septic shock, several goals are set. However, usually not all goals are equally met. The aim of this study is to determine the relative importance of the different goals, such as mean arterial pressure (MAP), lactate, central venous oxygen saturation (ScvO2) and central to forefoot temperature (delta-T), and how they relate to intensive care unit (ICU) and hospital mortality.
In a retrospective cohort study in a 20-bed mixed medical and surgical ICU of a teaching hospital we studied consecutive critically ill patients who were admitted for confirmed infection and severe sepsis or septic shock between 2008 and 2014. All validated MAP, lactate levels, ScvO2 and delta-T for the first 24 hours of ICU treatment were extracted from a clinical database. Logistic regression analyses were performed on validated measurements in the first hour after admission and on mean values over 24 hours. Patients were categorized by MAP (24-hour mean below or above 65 mmHg) and lactate (24-hour mean below or above 2 mmol/l) for Cox regression analysis.
From 837 patients, 821 were eligible for analysis. All had MAP and lactate measurements. The delta-T was available in 812 (99%) and ScvO2 was available for 193 out of these patients (23.5%). Admission lactate (p < 0.001) and admission MAP (p < 0.001) were independent predictors of ICU and hospital mortality. The 24-hour mean values for lactate, MAP and delta-T were all independent predictors of ICU mortality. Hospital mortality was independently predicted by the 24-hour mean lactate (odds ratio (OR) 1.34, 95% confidence interval (CI) 1.30-1.40, p = 0.001) mean MAP (OR 0.96, 95% CI 0.95-0.97, p = 0.001) and mean delta-T (OR 1.09, 95% CI 1.06-1.12, p = 0.001). Patients with a 24-hour mean lactate below 2 mmol/l and a 24-hour mean MAP above 65 mmHg had the best survival, followed by patients with a low lactate and a low MAP.
Admission MAP and lactate independently predicted ICU and hospital mortality. The 24-hour mean lactate, mean MAP and mean delta-T independently predicted hospital mortality. A Cox regression analysis showed that 24-hour mean lactate above 2 mmol/l is the strongest predictor for ICU mortality.
在严重脓毒症和脓毒性休克的复苏过程中，设定了多个目标。然而，通常并非所有目标都能同样实现。本研究的目的是确定不同目标的相对重要性，如平均动脉压（MAP）、乳酸、中心静脉血氧饱和度（ScvO2）和中心与前足温度差（delta-T），以及它们与重症监护病房（ICU）死亡率和医院死亡率之间的关系。
在一家教学医院拥有20张床位的内科和外科混合ICU进行的一项回顾性队列研究中，我们研究了2008年至2014年间因确诊感染以及严重脓毒症或脓毒性休克而入院的连续重症患者。从临床数据库中提取了ICU治疗最初24小时内所有经过验证的MAP、乳酸水平、ScvO2和delta-T数据。对入院后第一小时的验证测量值以及24小时的平均值进行逻辑回归分析。根据MAP（24小时平均值低于或高于65 mmHg）和乳酸（24小时平均值低于或高于2 mmol/l）对患者进行分类，以进行Cox回归分析。
837例患者中，821例符合分析条件。所有患者均有MAP和乳酸测量值。812例（99%）有delta-T数据，其中193例（23.5%）有ScvO2数据。入院时的乳酸水平（p < 0.001）和入院时的MAP（p < 0.001）是ICU死亡率和医院死亡率的独立预测因素。乳酸、MAP和delta-T的24小时平均值均是ICU死亡率的独立预测因素。医院死亡率的独立预测因素为24小时平均乳酸水平（比值比（OR）1.34，95%置信区间（CI）1.30 - 1.40，p = 0.001）、平均MAP（OR 0.96，95% CI 0.95 - 0.97，p = 0.001）和平均delta-T（OR 1.09，95% CI 1.06 - 1.12，p = 0.001）。24小时平均乳酸水平低于2 mmol/l且24小时平均MAP高于65 mmHg的患者生存率最佳，其次是乳酸水平低且MAP低的患者。
入院时的MAP和乳酸水平独立预测ICU死亡率和医院死亡率。24小时平均乳酸水平、平均MAP和平均delta-T独立预测医院死亡率。Cox回归分析表明，24小时平均乳酸水平高于2 mmol/l是ICU死亡率最强的预测因素。
