Dudaryk Roman, Navas-Blanco Jose R, Ferreira Tanira D, Epstein Richard H
Anesthesiology, University of Miami, Miami, USA.
Pulmonary Medicine, University of Miami, Miami, USA.
Cureus. 2021 Feb 13;13(2):e13326. doi: 10.7759/cureus.13326.
Introduction A sepsis bundle instituted by the Centers for Medicare and Medicaid Services, known as SEP-1, mandates remeasuring lactate concentrations in patients with suspected sepsis who have an initial lactate level ≥ 2.0 mmol/L to identify those at risk of mortality or clinical deterioration. However, in the group with an intermediate lactate level (2.0 - 3.9 mmol/L), evidence for the predictive utility for such practice is lacking. The objective of this retrospective cohort study was to evaluate the potential utility of repeating the blood lactate measurement for the premonitory detection of clinical deterioration in patients admitted to a ward with a diagnosis of suspected sepsis and an initial intermediate lactate level. Methods Using electronic health records, we retrospectively evaluated all non-hospice adult patients admitted from the emergency department to a ward of an academic medical center between October 1, 2017, and November 30, 2019, in whom a blood culture was obtained on admission as part of their workup for suspected sepsis. Patient demographics, the times and values of lactate concentrations, the occurrence of subsequent intensive care unit (ICU) transfer during the admission, and hospital mortality were determined. We computed the relative risk of ICU transfer (i.e., clinical deterioration) and hospital mortality in patients whose initial lactate was in the intermediate range who failed to reduce their lactate concentration by at least 10% within six hours. We hypothesized that failure to clear the lactate would be associated with an increased risk of ICU transfer and hospital mortality. Results We studied 12,157 patients, of whom 25 hospice patients were excluded. Of the remaining 12,132 patients, 1,416 (11.7%) were initially admitted to an intensive care unit, and 10,716 (88.3%) were admitted to a ward. Repeat lactate determinations were performed in 10.7%, 77.1%, and 90.2% of the ward patients with initial normal (< 2.0 mmol/L), intermediate (2.0 - 3.99 mmol/L), and high (≥ 4.0 mmol/L) admission lactate concentrations, respectively. There was no increase in the relative risk of ICU transfer (relative risk [RR] = 0.90, 95% CI, 0.53 - 1.28, P = 0.55) or hospital mortality (RR = 1.23, 95% CI, 0.85 - 1.79, P = 0.27) within the intermediate lactate level group among those whose lactate remained within 10% of the initial value (i.e., no change) or increased by more than 10%, compared to those in whom the level decreased by more than 10%. Conclusions Failure to reduce lactate concentrations in ward patients admitted with possible sepsis and an intermediate lactate level was not associated with an increased risk of ICU transfer or mortality. These results call into question the mandate in SEP-1 to routinely repeat the lactate determination in patients presenting with an intermediate concentration.
引言 医疗保险和医疗补助服务中心制定的一项脓毒症集束化治疗方案（称为SEP-1）要求，对于初始乳酸水平≥2.0 mmol/L的疑似脓毒症患者，重新测量其乳酸浓度，以识别有死亡或临床恶化风险的患者。然而，在乳酸水平处于中间范围（2.0 - 3.9 mmol/L）的患者群体中，缺乏此类做法具有预测效用的证据。这项回顾性队列研究的目的是评估，对于诊断为疑似脓毒症且初始乳酸水平处于中间范围而入住病房的患者，重复进行血乳酸测量对临床恶化的预警检测的潜在效用。方法 我们利用电子健康记录，回顾性评估了2017年10月1日至2019年11月30日期间从急诊科入住一所学术医疗中心病房的所有非临终关怀成年患者，这些患者入院时进行了血培养，作为疑似脓毒症检查的一部分。确定了患者的人口统计学特征、乳酸浓度的时间和数值、入院期间随后转入重症监护病房（ICU）的情况以及医院死亡率。我们计算了初始乳酸处于中间范围且在6小时内未能将乳酸浓度至少降低10%的患者转入ICU（即临床恶化）和医院死亡的相对风险。我们假设未能清除乳酸会增加转入ICU和医院死亡的风险。结果 我们研究了12157例患者，其中25例临终关怀患者被排除。在其余12132例患者中，1416例（11.7%）最初入住重症监护病房，10716例（88.3%）入住病房。初始乳酸浓度正常（<2.0 mmol/L）、处于中间范围（2.0 - 3.99 mmol/L）和较高（≥4.0 mmol/L）的病房患者中，分别有10.7%、77.1%和90.2%进行了重复乳酸测定。与乳酸水平下降超过10%的患者相比，乳酸水平保持在初始值的10%以内（即无变化）或升高超过10%的中间乳酸水平组患者，其转入ICU的相对风险（相对风险[RR]=0.90，95%置信区间，0.53 - 1.28，P=0.55）或医院死亡风险（RR=1.23，95%置信区间，0.85 - 1.79，P=0.27）均未增加。结论 对于因可能的脓毒症入院且乳酸水平处于中间范围的病房患者，未能降低乳酸浓度与转入ICU或死亡风险增加无关。这些结果对SEP-1中要求对乳酸浓度处于中间范围的患者常规重复测定乳酸的规定提出了质疑。
