Leisman Daniel E, Zemmel D'Amore Jason A, Gribben Jeanie L, Ward Mary Frances, Masick Kevin D, Bianculli Andrea R, Bradburn Kathryn H, D'Angelo John K, Doerfler Martin E
Department of Emergency Medicine, Hofstra-Northwell School of Medicine, Hempstead, NY, United States; Icahn School of Medicine at Mount Sinai, New York, NY, United States.
Department of Emergency Medicine, Hofstra-Northwell School of Medicine, Hempstead, NY, United States.
Am J Emerg Med. 2017 Jun;35(6):811-818. doi: 10.1016/j.ajem.2017.01.029. Epub 2017 Jan 15.
To compare the association of 3-h sepsis bundle compliance with hospital mortality in non-hypotensive sepsis patients with intermediate versus severe hyperlactemia.
This was a cohort study of all non-hypotensive, hyperlactemic sepsis patients captured in a prospective quality-improvement database, treated October 2014 to September 2015 at five tertiary-care centers. We defined sepsis as 1) infection, 2) ≥2 SIRS criteria, and 3) ≥1 organ dysfunction criterion. "Time-zero" was the first time a patient met all sepsis criteria.
systolic blood pressure>90 mmHg, mean arterial pressure>65 mmHg, and serum lactate≥2.2 mmol/L. Primary exposures: 1) intermediate(2.2-3.9 mmol/L) versus severe(≥4.0 mmol/L) hyperlactemia and 2) full 3-h bundle compliance. Bundle elements: The primary outcome was 60-day in-hospital mortality.
2417 patients met inclusion criteria. 704(29%) had lactate≥4.0 mmol/L versus 1775 patients with lactate 2.2-3.9 mmol/L. Compliance was 75% for antibiotics and 53% for fluids. Full-compliance was comparable between lactate groups (n=200(29%) and 488(28%), respectively). We observed 424(17.5%) mortalities: intermediate/non-compliant - 182(14.9%), intermediate/compliant - 41(8.4%), severe/non-compliant - 147(29.2%), severe/compliant - 54(27.0%) [difference-of-differences=4.3%, CI=2.6-5.9%]. In multivariable regression, mortality predictors included severe hyperlactemia (OR=1.99, CI=1.51-2.63) and bundle compliance (OR=0.62, CI=0.42-0.90), and their interaction was significant: p=0.022.
We observed a significant interaction between 3-h bundle compliance and initial hyperlactemia. Bundle compliance may be associated with greater mortality benefit for non-hypotensive sepsis patients with less severe hyperlactemia.
比较在非低血压性脓毒症患者中，中度与重度高乳酸血症患者3小时脓毒症集束化治疗依从性与医院死亡率之间的关联。
这是一项队列研究，纳入了前瞻性质量改进数据库中2014年10月至2015年9月在五个三级医疗中心接受治疗的所有非低血压性、高乳酸血症性脓毒症患者。我们将脓毒症定义为：1）感染，2）≥2条全身炎症反应综合征（SIRS）标准，以及3）≥1条器官功能障碍标准。“时间零点”是患者首次满足所有脓毒症标准的时间。
收缩压>90 mmHg，平均动脉压>65 mmHg，血清乳酸≥2.2 mmol/L。主要暴露因素：1）中度（2.2 - 3.9 mmol/L）与重度（≥4.0 mmol/L）高乳酸血症，以及2）3小时集束化治疗的完全依从性。集束化治疗要素：主要结局为60天院内死亡率。
2417例患者符合纳入标准。704例（29%）乳酸≥4.0 mmol/L，1775例患者乳酸为2.2 - 3.9 mmol/L。抗生素依从率为75%，液体依从率为53%。乳酸组间的完全依从性相当（分别为n = 200例（29%）和488例（28%））。我们观察到424例（17.5%）死亡病例：中度/不依从 - 182例（14.9%），中度/依从 - 41例（8.4%），重度/不依从 - 147例（29.2%），重度/依从 - 54例（27.0%）[差异差值 = 4.3%，CI = 2.6 - 5.9%]。在多变量回归分析中，死亡率预测因素包括重度高乳酸血症（OR = 1.99，CI = 1.51 - 2.63）和集束化治疗依从性（OR = 0.62，CI = 0.42 - 0.90），且它们之间的相互作用具有显著性：p = 0.022。
我们观察到3小时集束化治疗依从性与初始高乳酸血症之间存在显著的相互作用。对于高乳酸血症不太严重的非低血压性脓毒症患者，集束化治疗依从性可能与更大的死亡率获益相关。
