Ahmed Walid, Laimoud Mohamed
Critical Care Medicine Department, Cairo University, Cairo, Egypt.
Crit Care Res Pract. 2021 Sep 25;2021:6918940. doi: 10.1155/2021/6918940. eCollection 2021.
Achieving hemodynamic stabilization does not prevent progressive tissue hypoperfusion and organ dysfunction during resuscitation of septic shock patients. Many indicators have been proposed to judge the optimization of oxygen delivery to meet tissue oxygen consumption.
A prospective observational study was conducted to evaluate and validate combining CO gap and oxygen-derived variables with lactate clearance during early hours of resuscitation of adults presenting with septic shock.
Our study included 456 adults with a mean age of 63.2 ± 6.9 years, with 71.9% being males. Respiratory and urinary infections were the origin of about 75% of sepsis. Mortality occurred in 164 (35.9%) patients. The APACHE II score was 18.2 ± 3.7 versus 34.3 ± 6.8 ( < 0.001), the initial SOFA score was 5.8 ± 3.1 versus 7.3 ± 1.4 (=0.001), while the SOFA score after 48 hours was 4.2 ± 1.8 versus 9.4 ± 3.1 ( < 0.001) in the survivors and nonsurvivors, respectively. Hospital mortality was independently predicted by hyperlactatemia (OR: 2.47; 95% CI: 1.63-6.82, =0.004), PvaCO gap (OR: 2.62; 95% CI: 1.28-6.74, =0.026), PvaCO/CavO ratio (OR: 2.16; 95% CI: 1.49-5.74, =0.006), and increased SOFA score after 48 hours of admission (OR: 1.86; 95% CI: 1.36-8.13, =0.02). A blood lactate cutoff of 40 mg/dl at the 6th hour of resuscitation (T6) had a 92.7% sensitivity and 75.3% specificity for predicting hospital mortality (AUROC = 0.902) with 81.6% accuracy. Combining the lactate cutoff of 40 mg/dl and PvaCO/CavO ratio cutoff of 1.4 increased the specificity to 93.2% with a sensitivity of 75.6% in predicting mortality and with 86.8% accuracy. Combining the lactate cutoff of 40 mg/dl and PvaCO gap of 6 mmHg increased the sensitivity to 93% and increased the specificity to 98% in predicting mortality with 91% accuracy.
Combining the carbon dioxide gap and arteriovenous oxygen difference with lactate clearance during early hours of resuscitation of septic shock patients helps to predict hospital mortality more accurately.
在感染性休克患者的复苏过程中，实现血流动力学稳定并不能防止组织灌注不足和器官功能障碍的进展。已经提出了许多指标来判断氧输送优化以满足组织氧消耗的情况。
进行了一项前瞻性观察性研究，以评估和验证在感染性休克成年患者复苏早期将二氧化碳差值和氧衍生变量与乳酸清除率相结合的情况。
我们的研究纳入了456名成年人，平均年龄为63.2±6.9岁，其中71.9%为男性。呼吸和泌尿系统感染是约75%脓毒症的病因。164例（35.9%）患者死亡。存活者和非存活者的急性生理与慢性健康状况评分系统（APACHE II）评分为18.2±3.7对34.3±6.8（<0.001），初始序贯器官衰竭评估（SOFA）评分为5.8±3.1对7.3±1.4（=0.001），而复苏48小时后的SOFA评分分别为4.2±1.8对9.4±3.1（<0.001）。高乳酸血症（比值比：2.47；95%置信区间：1.63 - 6.82，=0.004）、静脉血二氧化碳分压与动脉血二氧化碳分压差值（PvaCO₂差值，比值比：2.62；95%置信区间：1.28 - 6.74，=0.026）、PvaCO₂/CaO₂比值（比值比：2.16；95%置信区间：1.49 - 5.74，=0.006）以及入院48小时后SOFA评分增加（比值比：1.86；95%置信区间：1.36 - 8.13，=0.02）可独立预测医院死亡率。复苏第6小时（T6）时血乳酸阈值为40mg/dl对预测医院死亡率的敏感性为92.7%，特异性为75.3%（受试者工作特征曲线下面积=0.902），准确率为81.6%。将40mg/dl的乳酸阈值与1.4的PvaCO₂/CaO₂比值阈值相结合，预测死亡率时特异性提高到93.2%，敏感性为75.6%，准确率为86.8%。将40mg/dl的乳酸阈值与6mmHg的PvaCO₂差值相结合，预测死亡率时敏感性提高到93%，特异性提高到98%，准确率为91%。
在感染性休克患者复苏早期将二氧化碳差值和动静脉氧差与乳酸清除率相结合有助于更准确地预测医院死亡率。
