Cidade José Pedro, Coelho L M, Costa Vasco, Morais Rui, Moniz Patrícia, Morais Luís, Fidalgo Pedro, Tralhão António, Paulino Carolina, Nora David, Valério Bernardino, Mendes Vítor, Tapadinhas Camila, Povoa Pedro
Polyvalent Intensive Care Unit, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisboa 1449-005, Portugal.
Polyvalent Intensive Care Unit, Hospital Sao Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisbon 1449-005, Portugal.
World J Crit Care Med. 2022 Jul 9;11(4):246-254. doi: 10.5492/wjccm.v11.i4.246.
Coronavirus disease 2019 (COVID-19) can be associated with life-threatening organ dysfunction due to septic shock, frequently requiring intensive care unit (ICU) admission, respiratory and vasopressor support. Therefore, clear clinical criteria are pivotal for early recognition of patients more likely to need prompt organ support. Although most patients with severe COVID-19 meet the Sepsis-3.0 criteria for septic shock, it has been increasingly recognized that hyperlactatemia is frequently absent, possibly leading to an underestimation of illness severity and mortality risk.
To identify the proportion of severe COVID-19 patients with vasopressor support requirements, with and without hyperlactatemia, and describe their clinical outcomes and mortality.
We performed a single-center prospective cohort study. All adult patients admitted to the ICU with COVID-19 were included in the analysis and were further divided into three groups: Sepsis group, without both criteria; Vasoplegic Shock group, with persistent hypotension and vasopressor support without hyperlactatemia; and Septic Shock 3.0 group, with both criteria. COVID-19 was diagnosed using clinical and radiologic criteria with a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive RT-PCR test.
118 patients (mean age 63 years, 87% males) were included in the analysis ( = 51 Sepsis group, = 26 Vasoplegic Shock group, and = 41 Septic Shock 3.0 group). SOFA score at ICU admission and ICU length of stay were different between the groups ( < 0.001). Mortality was significantly higher in the Vasoplegic Shock and Septic Shock 3.0 groups when compared with the Sepsis group ( < 0.001) without a significant difference between the former two groups ( = 0.713). The log rank tests of Kaplan-Meier survival curves were also different ( = 0.007). Ventilator-free days and vasopressor-free days were different between the Sepsis Vasoplegic Shock and Septic Shock 3.0 groups (both < 0.001), and similar in the last two groups ( = 0.128 and = 0.133, respectively). Logistic regression identified the maximum dose of vasopressor therapy used (AOR 1.046; 95%CI: 1.012-1.082, = 0.008) and serum lactate level (AOR 1.542; 95%CI: 1.055-2.255, = 0.02) as the major explanatory variables of mortality rates ( 0.79).
In severe COVID-19 patients, the Sepsis 3.0 criteria of septic shock may exclude approximately one third of patients with a similarly high risk of a poor outcome and mortality rate, which should be equally addressed.
2019年冠状病毒病（COVID-19）可因感染性休克导致危及生命的器官功能障碍，常需入住重症监护病房（ICU），接受呼吸和血管活性药物支持。因此，明确的临床标准对于早期识别更可能需要及时器官支持的患者至关重要。尽管大多数重症COVID-19患者符合感染性休克的脓毒症-3.0标准，但人们越来越认识到高乳酸血症常常不存在，这可能导致对疾病严重程度和死亡风险的低估。
确定有血管活性药物支持需求的重症COVID-19患者中，伴有和不伴有高乳酸血症的患者比例，并描述其临床结局和死亡率。
我们进行了一项单中心前瞻性队列研究。所有因COVID-19入住ICU的成年患者均纳入分析，并进一步分为三组：脓毒症组，不符合两项标准；血管麻痹性休克组，有持续性低血压且接受血管活性药物支持但无高乳酸血症；脓毒性休克3.0组，符合两项标准。COVID-19根据临床和影像学标准诊断，并伴有严重急性呼吸综合征冠状病毒2（SARS-CoV-2）阳性逆转录聚合酶链反应（RT-PCR）检测结果。
118例患者（平均年龄63岁，87%为男性）纳入分析（脓毒症组51例，血管麻痹性休克组26例，脓毒性休克3.0组41例）。各组间ICU入院时序贯器官衰竭评估（SOFA）评分和ICU住院时间不同（P<0.001）。与脓毒症组相比，血管麻痹性休克组和脓毒性休克3.0组的死亡率显著更高（P<0.001），前两组之间无显著差异（P=0.713）。Kaplan-Meier生存曲线的对数秩检验也不同（P=0.007）。脓毒症组、血管麻痹性休克组和脓毒性休克3.0组之间无呼吸机天数和无血管活性药物天数不同（均P<0.001），后两组相似（分别为P=0.128和P=0.133）。逻辑回归确定使用的血管活性药物治疗最大剂量（比值比1.046；95%置信区间：1.***-1.082，P=0.008）和血清乳酸水平（比值比1.542；95%置信区间：1.055-2.255，P=0.02）为死亡率的主要解释变量（R²=0.79）。
在重症COVID-19患者中，脓毒性休克的脓毒症-3.0标准可能排除了约三分之一结局不良和死亡率风险同样高的患者，对此应予以同等关注。
