用于评估死亡率的新型院前乳酸临界值估计：一项多中心观察性研究。
Novel prehospital lactate cut-off estimation for mortality: a multicentre observational study.
作者信息
Martín-Rodríguez Francisco, Sanz-Garcia Ancor, Zalama-Sánchez Daniel, de Santos Castro Pedro Ángel, Silva Alvarado Eduardo, Gracia Villar Santos, Dzul López Luis Alonso, Aparicio Obregón Silvia, Calderon Iglesias Rubén, Del Pozo Vegas Carlos, López-Izquierdo Raúl
机构信息
Universidad de Valladolid, Valladolid, Spain.
University of Castilla-La Mancha, Ciudad Real, Spain
出版信息
BMJ Open. 2024 Dec 20;14(12):e091789. doi: 10.1136/bmjopen-2024-091789.
OBJECTIVES
Point-of-care testing available in prehospital settings requires the establishment of new medical decision points. The aim of the present work was to determine the cut-off of the lactate threshold that activates alert triggers for all-cause 2-day mortality.
DESIGN
Multicentre, prospective, ambulance-based, observational study.
SETTING
Patients treated via emergency medical services (EMSs) and delivered to the emergency department between 2019 and 2023 were selected in Spain.
PARTICIPANTS
Adults with any acute disease.
PRIMARY AND SECONDARY OUTCOME MEASURES
Epidemiological data, vital signs and prehospital point-of-care glucose and lactate levels were obtained. The outcome was all-cause 2-day in-hospital mortality. The cut-offs were obtained via three different methods: (i) indirect (which considers survivors and non-survivors), direct (which considers only survivors) assessment and lactate quartile. Additionally, the quartile approach was used to determine the differences in lactate distribution between survivors and non-survivors. Three different back-to-back studies with the same methodology were used.
RESULTS
A total of 11 713 patients fulfilled the inclusion criteria. The mortality rate was 4.6% (542 patients). The difference in the median prehospital lactate concentration (mmol/L) between survivors and non-survivors was statistically significant (p<0.001): 2.29 (95% CI 1.43 to 3.38) and 7.14 (95% CI 5.11 to 9.71), respectively. Globally, the cut-off for all the studies combined was estimated by the direct method to be 3.71 mmol/L (95% CI 2.92 to 3.91), which was similar to the indirect value of 3.07 (95% CI 2.95 to 5.49) and the third quartile of 4.00. The mortality rate in patients who were less than 3.71 mmol/L was 0.004%, and that above that cut-off was 18%.
CONCLUSIONS
This study established a real-world lactate cut-off for 2-day in-hospital mortality of 3.71 mmol/L (95% CI 2.92 to 3.91) on the basis of data from the EMS. Considering this cut-off point could improve patient management via EMS services, allowing quick identification of patients at high risk of clinical worsening.
TRIAL REGISTRATION NUMBER
ISRCTN Registry (ISRCTN17676798, ISRCTN48326533, ISRCTN49321933).
目的
院前环境中可用的即时检验需要建立新的医学决策点。本研究的目的是确定乳酸阈值的临界值，该临界值可触发全因2天死亡率的警报。
设计
多中心、前瞻性、基于救护车的观察性研究。
设置
在西班牙，选取2019年至2023年期间通过紧急医疗服务（EMS）治疗并送至急诊科的患者。
参与者
患有任何急性疾病的成年人。
主要和次要观察指标
获取流行病学数据、生命体征以及院前即时检验的血糖和乳酸水平。结局指标为全因2天住院死亡率。临界值通过三种不同方法获得：（i）间接法（考虑幸存者和非幸存者）、直接法（仅考虑幸存者）评估以及乳酸四分位数法。此外，四分位数法用于确定幸存者和非幸存者之间乳酸分布的差异。使用了三项采用相同方法的背对背研究。
结果
共有11713名患者符合纳入标准。死亡率为4.6%（542例患者）。幸存者和非幸存者之间院前乳酸浓度中位数（mmol/L）的差异具有统计学意义（p<0.001）：分别为2.29（95%CI 1.43至3.38）和7.14（95%CI 5.11至9.71）。总体而言，所有研究综合得出的临界值，直接法估计为3.71 mmol/L（95%CI 2.92至3.91），与间接值3.07（95%CI 2.95至5.49）和第三四分位数4.00相似。乳酸浓度低于3.71 mmol/L的患者死亡率为0.004%，高于该临界值的患者死亡率为18%。
结论
本研究基于EMS数据确定了2天住院死亡率的实际乳酸临界值为3.71 mmol/L（95%CI 2.92至3.91）。考虑这个临界值可以通过EMS服务改善患者管理，有助于快速识别临床恶化风险高的患者。
试验注册号
ISRCTN注册库（ISRCTN17676798、ISRCTN48326533、ISRCTN49321933）
Zotero 插件