血清乳酸临界值作为筛查疑似脓毒症的急诊科患者院内不良结局风险分层工具。

Serum lactate cut-offs as risk stratification tool for in-hospital adverse outcomes in emergency department patients screened for suspected sepsis.

作者信息

Shetty Amith L, Thompson Kelly, Byth Karen, Macaskill Petra, Green Malcolm, Fullick Mary, Lander Harvey, Iredell Jonathan

机构信息

NHMRC Centre for Research Excellence in Critical Excellence, Westmead Millennium Institute for Medical Research, Westmead, New South Wales, Australia.

Emergency Department, Westmead Hospital, Westmead, New South Wales, Australia.

出版信息

BMJ Open. 2018 Jan 5;8(1):e015492. doi: 10.1136/bmjopen-2016-015492.

DOI:10.1136/bmjopen-2016-015492

PMID:29306875

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC5780682/

Abstract

OBJECTIVES

We investigated specific lactate thresholds for adverse outcomes in patients presenting to emergency departments (EDs) with suspected sepsis identified based on the performance of a sepsis screening algorithm.

DESIGN AND SETTING

A standardised sepsis bundle was implemented across public hospitals in New South Wales, Australia, as a quality improvement initiative. A register of all adult ED presentations (≥18 years) meeting predefined criteria for sepsis was created, using a combination of data linkage and direct reporting from 97 participating sites.

PARTICIPANTS

A total of 12 349 adult ED presentations with 8310 (67.3%) having serum lactate analysis on arrival. Analysis of outcomes was based on dataset for 12 349 subjects obtained through multiple imputation for missing data.

INTERVENTIONS

A sepsis management bundle including early antibiotic prescribing, fluid therapy and referral to intensive care unit (ICU) services was implemented.

OUTCOME MEASURES

A primary composite adverse event (AE) outcome of inhospital mortality (IHM) and/or prolonged ICU stay ≥72 hours (ICU 72 hours) was used for this study.

RESULTS

There was statistically significant increase both in the ORs of AE and IHM with each integer increase in serum lactate values. After adjusting for the presence of hypotension, the estimated ORs for the combined AE outcome were 2.71 (95% CI 2.05 to 3.57), 2.65 (95% CI 2.29 to 3.08), 3.10 (95% CI 2.71 to 3.53) and 3.89 (95% CI 3.36 to 4.50) for serum lactate levels at or above 1, 2, 3 and 4 mmol/L, respectively. The corresponding ORs for IHM were 2.93 (95% CI 2.08 to 4.13), 2.77 (95% CI 2.34 to 3.29), 3.26 (95% CI 2.80 to 3.80) and 4.01 (95% CI 3.40 to 4.73), respectively (all P<0.0001). More than 10% of patients with suspected sepsis and with serum lactate ≥2 mmol/L experienced a prolonged ICU stay or died in hospital.

CONCLUSIONS

ED sepsis screening algorithms intended to identify patient adverse outcomes should incorporate a serum lactate cut-off of ≥2 mmol/L as a threshold for the initiation of specific interventions and increased monitoring.

摘要

目的

我们基于脓毒症筛查算法的表现，对因疑似脓毒症前往急诊科（ED）就诊的患者发生不良结局的特定乳酸阈值进行了调查。

设计与背景

作为一项质量改进举措，澳大利亚新南威尔士州的公立医院实施了标准化的脓毒症治疗集束方案。通过数据链接和97个参与站点的直接报告相结合的方式，创建了一个登记册，记录所有符合脓毒症预定义标准的成年急诊就诊患者（≥18岁）。

参与者

共有12349例成年急诊就诊患者，其中8310例（67.3%）在到达时进行了血清乳酸分析。结局分析基于通过对缺失数据进行多次插补获得的12349名受试者的数据集。

干预措施

实施了包括早期抗生素处方、液体治疗和转诊至重症监护病房（ICU）服务的脓毒症管理集束方案。

结局指标

本研究采用住院死亡率（IHM）和/或ICU住院时间延长≥72小时（ICU 72小时）这一主要复合不良事件（AE）结局指标。

结果

血清乳酸值每增加一个整数，AE和IHM的比值比（OR）均有统计学显著增加。在调整低血压因素后，血清乳酸水平在1 mmol/L及以上、2 mmol/L及以上、3 mmol/L及以上和4 mmol/L及以上时，联合AE结局的估计OR分别为2.71（95%可信区间2.05至3.57）、2.65（95%可信区间2.29至3.08）、3.10（95%可信区间2.71至3.53）和3.89（95%可信区间3.36至4.50）。IHM的相应OR分别为2.93（95%可信区间2.08至4.13）、2.77（95%可信区间2.34至3.29）、3.26（95%可信区间2.80至3.80）和4.01（95%可信区间3.40至4.73）（均P<0.0001）。超过10%的疑似脓毒症且血清乳酸≥2 mmol/L的患者经历了ICU住院时间延长或在医院死亡。