Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA.
Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA.
Hepatol Commun. 2024 Jan 5;8(1). doi: 10.1097/HC9.0000000000000353. eCollection 2024 Jan 1.
The Sepsis-3 guidelines have incorporated serum lactate levels of >2 mmol/L in septic shock definition to account for higher observed mortality. Further evidence is needed to support this threshold in cirrhosis, as well as target mean arterial pressure (MAP) during resuscitation.
This observational cohort study investigated the association between initial serum lactate and resuscitation MAP levels on in-hospital mortality in patients with and without cirrhosis. Patients admitted to the intensive care unit for the treatment of septic shock between 2006 and 2021 in a quaternary academic center were included. Patients with cirrhosis documented on imaging and International Classification of Disease codes (n=595) were compared to patients without cirrhosis (n=575). The association of intensive care unit admission lactate levels and median 2-hour MAP with in-hospital mortality and the need for continuous renal replacement therapy was assessed. The association between median 24-hour MAP and in-hospital mortality was analyzed post hoc.
Within the cirrhosis group, admission lactate levels of 2-4 and >4 mmol/L were associated with increased in-hospital mortality compared to lactate <2 mmol/L [adjusted odds ratio (aOR): 1.69, CI: 1.03-2.81, aOR: 4.02, CI: 2.53-6.52]. Median 24-hour MAP 60-65 and <60 mm Hg were also associated with increased in-hospital mortality compared with MAP >65 mm Hg (aOR: 2.84, CI: 1.64-4.92 and aOR: 7.34, CI: 3.17-18.76). In the noncirrhosis group, associations with in-hospital mortality were weaker for lactate 2-4 and >4 mmol/L (aOR: 1.32, CI: 0.77-2.27 and aOR: 2.25, CI: 1.40-3.67) and median 24-hour MAP 60-65 and <60 mm Hg (aOR: 1.70, CI: 0.65-4.14 and aOR: 4.41, CI: 0.79-29.38).
These findings support utilizing lactate >2 mmol/L in the definition of septic shock, as well as a target MAP of >65 mm Hg during resuscitation in patients with cirrhosis.
Sepsis-3 指南将血清乳酸水平 >2 mmol/L 纳入脓毒性休克定义，以解释观察到的死亡率升高。需要进一步的证据来支持肝硬化中这一阈值，以及复苏期间的平均动脉压（MAP）目标。
本观察性队列研究调查了初始血清乳酸水平与肝硬化患者和非肝硬化患者住院死亡率之间的关系。纳入 2006 年至 2021 年期间在一家四级学术中心因脓毒性休克入住重症监护病房的患者。对影像学和国际疾病分类编码（n=595）记录有肝硬化的患者与无肝硬化的患者（n=575）进行比较。评估重症监护病房入院时的乳酸水平和中位数 2 小时 MAP 与住院死亡率和持续肾脏替代治疗的关系。事后分析了中位数 24 小时 MAP 与住院死亡率之间的关系。
在肝硬化组中，与乳酸 <2 mmol/L 相比，乳酸 2-4 mmol/L 和 >4 mmol/L 与住院死亡率增加相关[校正比值比（aOR）：1.69，95%CI：1.03-2.81，aOR：4.02，95%CI：2.53-6.52]。中位数 24 小时 MAP 60-65 和 <60 mmHg 与 MAP >65 mmHg 相比，也与住院死亡率增加相关（aOR：2.84，95%CI：1.64-4.92 和 aOR：7.34，95%CI：3.17-18.76）。在非肝硬化组中，乳酸 2-4 mmol/L 和 >4 mmol/L （aOR：1.32，95%CI：0.77-2.27 和 aOR：2.25，95%CI：1.40-3.67）和中位数 24 小时 MAP 60-65 和 <60 mmHg（aOR：1.70，95%CI：0.65-4.14 和 aOR：4.41，95%CI：0.79-29.38）与住院死亡率的相关性较弱。
这些发现支持在肝硬化患者中使用乳酸 >2 mmol/L 来定义脓毒性休克，以及复苏期间 MAP 目标 >65 mmHg。
