Baysan Meryem, Arbous Mendi S, Steyerberg Ewout W, van der Bom Johanna G
Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands.
Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.
Crit Care Explor. 2022 Sep 2;4(9):e0750. doi: 10.1097/CCE.0000000000000750. eCollection 2022 Sep.
We previously reported the added value of 24-hour lactate concentration alone and in combination with 24-hour lactate clearance and lactate concentration at admission for the prediction of inhospital mortality in critically ill patients with sepsis. We aimed to validate this finding.
The derivation cohort from Leiden, The Netherlands, consisted of 451 critically ill patients with sepsis.
The validation cohort consisted of 4,440 critically ill adult patients with sepsis from the Medical Information Mart for Intensive Care cohort admitted to the ICU of Beth Israel Deaconness Medical Center, Boston, MA, between January 2006 and 2018.
Predictors of mortality were: age, chronic comorbidities, length of stay pre-ICU, Glasgow Coma Scale, and Acute Physiology Score. Lactate concentration at 24-hour alone, in combination with 24-hour lactate clearance and in combination with lactate concentration at admission, was added to assess improvement of the prediction model. The outcome was inhospital mortality.
Inhospital mortality occurred in 160 patients (36%) in the derivation cohort and in 2,347 patients (53%) in the validation cohort. The Acute Physiology and Chronic Health Evaluation (APACHE) IV model had a moderate discriminative performance (recalibrated -statistic, 0.62; 95% CI, 0.60-0.63). Addition of 24-hour lactate concentration increased the recalibrated -statistic to 0.64 (95% CI, 0.62-0.66). The model with 24-hour lactate concentration and lactate concentration at admission showed the best fit as depicted by the smallest Akaike Information Criterion in both the derivation and validation data.
The 24-hour lactate concentration and lactate concentration at admission contribute modestly to prediction of inhospital mortality in critically ill patients with sepsis. Future updates and possible modification of APACHE IV should consider the incorporation of lactate concentration at baseline and at 24 hours.
我们之前报告了单独的24小时乳酸浓度以及联合24小时乳酸清除率和入院时乳酸浓度对预测脓毒症重症患者院内死亡率的附加价值。我们旨在验证这一发现。
来自荷兰莱顿的推导队列由451例脓毒症重症患者组成。
验证队列由2006年1月至2018年期间入住马萨诸塞州波士顿贝斯以色列女执事医疗中心重症监护病房的医学重症监护信息集市队列中的4440例脓毒症成年重症患者组成。
死亡率的预测因素包括：年龄、慢性合并症、入住重症监护病房前的住院时间、格拉斯哥昏迷量表和急性生理学评分。单独加入24小时乳酸浓度，联合24小时乳酸清除率以及联合入院时乳酸浓度，以评估预测模型的改进情况。结局指标为院内死亡率。
推导队列中有160例患者（36%）发生院内死亡，验证队列中有2347例患者（53%）发生院内死亡。急性生理学与慢性健康状况评估（APACHE）IV模型具有中等的鉴别性能（重新校准的C统计量，0.62；95%置信区间，0.60 - 0.63）。加入24小时乳酸浓度后，重新校准的C统计量增至0.64（95%置信区间，0.62 - 0.66）。在推导数据和验证数据中，具有24小时乳酸浓度和入院时乳酸浓度的模型以最小的赤池信息准则显示出最佳拟合。
24小时乳酸浓度和入院时乳酸浓度对预测脓毒症重症患者的院内死亡率有一定贡献。未来对APACHE IV的更新和可能的修改应考虑纳入基线和24小时时的乳酸浓度。
