Department of Emergency Medicine, University of Iowa College of Medicine, Iowa City, IA, United States; Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA, United States.
Department of Emergency Medicine, University of Iowa College of Medicine, Iowa City, IA, United States; Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, United States.
J Crit Care. 2018 Apr;44:223-228. doi: 10.1016/j.jcrc.2017.10.043. Epub 2017 Oct 31.
PURPOSE: (1) To test whether serum bicarbonate or anion gap can be used to predict elevated lactate or mortality in emergency department (ED) patients with sepsis, and (2) to define thresholds that may predict elevated lactate and mortality. METHODS: Retrospective diagnostic-validation study of adults with sepsis treated in a 60,000-visit Midwestern university ED (2010-2015). In the derivation sample, 8 experts selected thresholds based on objective measures to optimize clinical utility. Test performance was reported using likelihood ratios (LR +/-) in the validation cohort. RESULTS: We included 4159 patients. Anion gap predicted lactate>2 better than bicarbonate [ROC AUC 0.680 vs. 0.609], and anion gap predicted lactate>4 better than lactate>2 [ROC AUC 0.816 vs. 0.680]. In the validation cohort, anion gap ≥20mEq/L had LR+ for lactate>2 of 3.670 (2.630-5.122), lactate>4 of 7.019 (5.310-9.278), and mortality of 2.768 (1.922-3.986). Anion gap predicted mortality similar to lactate>2 [LR+ 2.768 vs. LR+ 2.09; LR- 0.823 vs. 0.447]. CONCLUSIONS: Anion gap and serum bicarbonate poorly predict changes in lactate and mortality. In resource-limited settings where lactate is unavailable, anion gap ≥20mEq/L may be used to further risk-stratify patients for ongoing sepsis care, but lactate remains a preferred biomarker.
目的：(1) 检验血清碳酸氢盐或阴离子间隙是否可用于预测急诊科（ED）患有脓毒症的患者乳酸升高或死亡，(2) 定义可能预测乳酸升高和死亡的阈值。
方法：对中西部一所拥有 60000 次就诊量的大学 ED（2010-2015 年）中治疗的脓毒症成年患者进行回顾性诊断验证研究。在推导样本中，8 位专家根据客观指标选择阈值，以优化临床实用性。在验证队列中，使用似然比（LR+/-）报告测试性能。
结果：我们纳入了 4159 名患者。阴离子间隙预测乳酸>2 比碳酸氢盐更好[ROC AUC 0.680 比 0.609]，阴离子间隙预测乳酸>4 比乳酸>2 更好[ROC AUC 0.816 比 0.680]。在验证队列中，阴离子间隙≥20mEq/L 对乳酸>2 的 LR+为 3.670（2.630-5.122），乳酸>4 的 LR+为 7.019（5.310-9.278），死亡率为 2.768（1.922-3.986）。阴离子间隙预测死亡率与乳酸>2 相似[LR+ 2.768 比 LR+ 2.09；LR- 0.823 比 0.447]。
结论：阴离子间隙和血清碳酸氢盐均不能很好地预测乳酸和死亡率的变化。在资源有限且无法获得乳酸的情况下，阴离子间隙≥20mEq/L 可用于进一步对患者进行分层，以进行持续的脓毒症治疗，但乳酸仍然是首选的生物标志物。
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