Herrero De Lucas Eva, Sanchez-Sanchez Manuel, Cachafeiro Fuciños Lucia, Agrifoglio Rotaeche Alexander, Martínez Mendez Jose Ramón, Flores Cabeza Eva, Millan Estañ Pablo, García-de-Lorenzo Abelardo
Servicio de Medicina Intensiva. Hospital Universitario La Paz-Cantoblanco-CarlosIII/IdiPAZ. Paseo de la Castellana 261. Madrid 28046. Spain.
Servicio de Medicina Intensiva. Hospital Universitario La Paz-Cantoblanco-CarlosIII/IdiPAZ. Paseo de la Castellana 261. Madrid 28046. Spain.
Burns. 2020 Dec;46(8):1839-1847. doi: 10.1016/j.burns.2020.06.003. Epub 2020 Jun 21.
Lactate levels to guide resuscitation in critically burned patients are controversial. The purpose of our study was to determine whether absolute lactate values or lower lactate clearance predict mortality, and whether these are useful tools in the resuscitation phase.
We conducted a prospective, unicentric, observational study of a cohort of 214 burn patients admitted in the Burn Intensive Care Unit. We collected demographic and laboratory data, complications, absolute lactate levels and lactate clearance every 8 h since admission to 72 h. In critical patients we monitored hemodynamic parameters with transpulmonary thermodilution. We used Student's t-test or nonparametric tests, mixed models and Pearson and Spearman methods, Fisher's exact and chi-squared test.
Of the 214 patients, 76.6% were male, mean age were 46 ± 15 years and 23.0 ± 19.5% of Total Basal Surface Area (TBSA) burned. Initial mean absolute levels of lactate were 2.02 ± 1.62 mmol/L in survivors vs. 4.05 ± 3.90 mmol/L in nonsurvivors. Initial elevated lactate levels increased mortality (p < .001), length of ICU stay, mechanical ventilation and shock. In the subgroup of burned TBSA < 20%, lowering the lactate cut-off point from 2.0 to 1.8 mmol/L improved the mortality prediction (OR:9.3). We found no relationship between lactate clearance in the first 24 h and mortality. In more severe patients (> 20% TBSA burned and initial lactate levels > 2), a good correlation was found between lactate and cardiac index; but not with intrathoracic blood volume index (ITBVI). Patients with low ITBVI preload (< 600 mL/m) did not show significant differences in lactate clearance compared with those with ITBVI > 600.
Initial elevated lactate levels are a factor of poor prognosis and the cut-off point that best predicts mortality should be adjusted in the patients with TBSA burned < 20%. The global clearance of lactate in the first 24 h, unlike what occurs in other injuries, does not correlate with mortality. Monitoring lactate can ensure adequate peripheral perfusion during resuscitation with lower than normal fluid preload values.
乳酸水平用于指导严重烧伤患者的复苏存在争议。我们研究的目的是确定绝对乳酸值或较低的乳酸清除率是否可预测死亡率，以及这些指标在复苏阶段是否为有用的工具。
我们对烧伤重症监护病房收治的214例烧伤患者进行了一项前瞻性、单中心观察性研究。自入院至72小时，每8小时收集患者的人口统计学和实验室数据、并发症、绝对乳酸水平及乳酸清除率。对于重症患者，我们采用经肺热稀释法监测血流动力学参数。我们使用了学生t检验或非参数检验、混合模型以及Pearson和Spearman方法、Fisher精确检验和卡方检验。
214例患者中，76.6%为男性，平均年龄为46±15岁，烧伤总面积（TBSA）为23.0±19.5%。幸存者初始乳酸平均绝对水平为2.02±1.62 mmol/L，非幸存者为4.05±3.90 mmol/L。初始乳酸水平升高会增加死亡率（p<0.001）、重症监护病房住院时间、机械通气时间和休克发生率。在烧伤TBSA<20%的亚组中，将乳酸临界值从2.0 mmol/L降至1.8 mmol/L可改善死亡率预测（OR：9.3）。我们发现24小时内的乳酸清除率与死亡率之间无关联。在更严重的患者（烧伤TBSA>20%且初始乳酸水平>2）中，乳酸与心脏指数之间存在良好相关性；但与胸腔内血容量指数（ITBVI）无关。与ITBVI>600的患者相比，ITBVI前负荷低（<600 mL/m）的患者在乳酸清除率方面无显著差异。
初始乳酸水平升高是预后不良的一个因素，对于烧伤TBSA<20%的患者，最能预测死亡率的临界值应进行调整。与其他损伤不同，24小时内乳酸的总体清除率与死亡率无关。监测乳酸可确保在复苏期间以低于正常的液体预负荷值实现充足的外周灌注。
