Occult hypoperfusion and mortality in patients with suspected infection

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• 作者：Michael D. Howell (1)
  Michael Donnino (2)
  Peter Clardy (1)
  Daniel Talmor (3)
  Nathan I. Shapiro (2)
  
• 关键词：Sepsis ; Infection ; Lactic acid/lactate ; Triage ; Prognosis ; Risk assessment
• 刊名：Intensive Care Medicine
• 出版年：2007
• 出版时间：November 2007
• 年：2007
• 卷：33
• 期：11
• 页码：1892-1899
• 全文大小：189KB
• 参考文献：1. Angus?DC, Linde-Zwirble?WT, Lidicker?J, Clermont?G, Carcillo?J, Pinsky?MR (2001) Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 29:1303-310 CrossRef
  2. Rivers?E, Nguyen?B, Havstad?S, Ressler?J, Muzzin?A, Knoblich?B, Peterson?E, Tomlanovich?M (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345:1368-377 CrossRef
  3. Brun-Buisson?C, Meshaka?P, Pinton?P, Vallet?B (2004) EPISEPSIS: a?reappraisal of the epidemiology and outcome of severe sepsis in French intensive care units. Intensive Care Med 30:580-88 CrossRef
  4. Alberti?C, Brun-Buisson?C, Burchardi?H, Martin?C, Goodman?S, Artigas?A, Sicignano?A, Palazzo?M, Moreno?R, Boulme?R, Lepage?E, Le Gall?R (2002) Epidemiology of sepsis and infection in ICU patients from an international multicentre cohort study. Intensive Care Med 28:108-21 CrossRef
  5. Dellinger?RP, Carlet?JM, Masur?H, Gerlach?H, Calandra?T, Cohen?J, Gea-Banacloche?J, Keh?D, Marshall?JC, Parker?MM, Ramsay?G, Zimmerman?JL, Vincent?JL, Levy?MM (2004) Surviving sepsis campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 32:858-73 CrossRef
  6. Shapiro?NI, Howell?MD, Talmor?D, Lahey?D, Ngo?L, Buras?J, Wolfe?RE, Weiss?JW, Lisbon?A (2006) Implementation and outcomes of the Multiple Urgent Sepsis Therapies (MUST) protocol. Crit Care Med 34:1025-032 CrossRef
  7. Kortgen?A, Niederprum?P, Bauer?M (2006) Implementation of an evidence-based “standard operating procedure-and outcome in septic shock. Crit Care Med 34:943-49 CrossRef
  8. Ander?DS, Jaggi?M, Rivers?E, Rady?MY, Levine?TB, Levine?AB, Masura?J, Gryzbowski?M (1998) Undetected cardiogenic shock in patients with congestive heart failure presenting to the emergency department. Am J Cardiol 82:888-91 CrossRef
  9. Rady?MY, Rivers?EP, Nowak?RM (1996) Resuscitation of the critically ill in the ED: responses of blood pressure, heart rate, shock index, central venous oxygen saturation, and lactate. Am J Emerg Med 14:218-25 CrossRef
  10. Meregalli?A, Oliveira?RP, Friedman?G (2004) Occult hypoperfusion is associated with increased mortality in hemodynamically stable, high-risk, surgical patients. Crit Care 8:R60-5 CrossRef
  11. Shapiro?NI, Howell?MD, Talmor?D, Nathanson?LA, Lisbon?A, Wolfe?RE, Weiss?JW (2005) Serum lactate as a?predictor of mortality in emergency department patients with infection. Ann Emerg Med 45:524-28 CrossRef
  12. Lavery?RF, Livingston?DH, Tortella?BJ, Sambol?JT, Slomovitz?BM, Siegel?JH (2000) The utility of venous lactate to triage injured patients in the trauma center. J Am Coll Surg 190:656-64 CrossRef
  13. Myint?PK, Kamath?AV, Vowler?SL, Maisey?DN, Harrison?BD (2005) The?CURB (confusion, urea, respiratory rate and blood pressure) criteria in community-acquired pneumonia (CAP) in hospitalised elderly patients aged 65 years and over: a?prospective observational cohort study. Age Ageing 34:75-7 CrossRef
  14. Shapiro?NI, Wolfe?RE, Moore?RB, Smith?E, Burdick?E, Bates?DW (2003) Mortality in Emergency Department Sepsis (MEDS) score: a?prospectively derived and validated clinical prediction rule. Crit Care Med 31:670-75 CrossRef
  15. Levy?MM, Fink?MP, Marshall?JC, Abraham?E, Angus?D, Cook?D, Cohen?J, Opal?SM, Vincent?JL, Ramsay?G (2003) 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 31:1250-256 CrossRef
  16. Blow?O, Magliore?L, Claridge?JA, Butler?K, Young?JS (1999) The golden hour and the silver day: detection and correction of occult hypoperfusion within 24 hours improves outcome from major trauma. J Trauma 47:964-69
  17. Crowl?AC, Young?JS, Kahler?DM, Claridge?JA, Chrzanowski?DS, Pomphrey?M (2000) Occult hypoperfusion is associated with increased morbidity in patients undergoing early femur fracture fixation. J Trauma 48:260-67
  18. Broder?G, Weil?MH (1964) Excess lactate: an index of reversibility of shock in human patients. Science 143:1457-459 CrossRef
  19. Bossink?AW, Groeneveld?AB, Koffeman?GI, Becker?A (2001) Prediction of shock in febrile medical patients with a?clinical infection. Crit Care Med 29:25-1 CrossRef
  20. Claridge?JA, Crabtree?TD, Pelletier?SJ, Butler?K, Sawyer?RG, Young?JS (2000) Persistent occult hypoperfusion is associated with a?significant increase in infection rate and mortality in major trauma patients. J Trauma 48:8-4; discussion 15
  21. Wo?CC, Shoemaker?WC, Appel?PL, Bishop?MH, Kram?HB, Hardin?E (1993) Unreliability of blood pressure and heart rate to evaluate cardiac output in emergency resuscitation and critical illness. Crit Care Med 21:218-23 CrossRef
  22. Bakker?J (2001) Lactate: may I have your votes please? Intensive Care Med 27:6-1 CrossRef
  23. Levraut?J, Ichai?C, Petit?I, Ciebiera?JP, Perus?O, Grimaud?D (2003) Low exogenous lactate clearance as an early predictor of mortality in normolactatemic critically ill septic patients. Crit Care Med 31:705-10 CrossRef
  24. Astiz?M, Rackow?EC, Weil?MH, Schumer?W (1988) Early impairment of oxidative metabolism and energy production in severe sepsis. Circ Shock 26:311-20
  25. Levraut?J, Ciebiera?JP, Chave?S, Rabary?O, Jambou?P, Carles?M, Grimaud?D (1998) Mild hyperlactatemia in stable septic patients is due to impaired lactate clearance rather than overproduction. Am J Respir Crit Care Med 157:1021-026
  26. Mizock?BA, Falk?JL (1992) Lactic acidosis in critical illness. Crit Care Med 20:80-3 CrossRef
  27. Bakker?J, Coffernils?M, Leon?M, Gris?P, Vincent?JL (1991) Blood lactate levels are superior to oxygen-derived variables in predicting outcome in human septic shock. Chest 99:956-62
  28. Bakker?J, Gris?P, Coffernils?M, Kahn?RJ, Vincent?JL (1996) Serial blood lactate levels can predict the development of multiple organ failure following septic shock. Am J Surg 171:221-26 CrossRef
  29. Varpula?M, Tallgren?M, Saukkonen?K, Voipio-Pulkki?LM, Pettila?V (2005) Hemodynamic variables related to outcome in septic shock. Intensive Care Med 31:1066-071 CrossRef
  30. Husain?FA, Martin?MJ, Mullenix?PS, Steele?SR, Elliott?DC (2003) Serum lactate and base deficit as predictors of mortality and morbidity. Am J Surg 185:485-91 CrossRef
  31. McNelis?J, Marini?CP, Jurkiewicz?A, Szomstein?S, Simms?HH, Ritter?G, Nathan?IM (2001) Prolonged lactate clearance is associated with increased mortality in the surgical intensive care unit. Am J Surg 182:481-85 CrossRef
  32. Jeng?JC, Jablonski?K, Bridgeman?A, Jordan?MH (2002) Serum lactate, not base deficit, rapidly predicts survival after major burns. Burns 28:161-66 CrossRef
  33. Cerovic?O, Golubovic?V, Spec-Marn?A, Kremzar?B, Vidmar?G (2003) Relationship between injury severity and lactate levels in severely injured patients. Intensive Care Med 29:1300-305 CrossRef
  34. Asimos?AW, Gibbs?MA, Marx?JA, Jacobs?DG, Erwin?RJ, Norton?HJ, Thomason?M (2000) Value of point-of-care blood testing in emergent trauma management. J Trauma 48:1101-108 CrossRef
  35. Jones?AE, Fitch?MT, Kline?JA (2005) Operational performance of validated physiologic scoring systems for predicting in-hospital mortality among critically ill emergency department patients. Crit Care Med 33:974-78 CrossRef
  36. Nguyen?HB, Rivers?EP, Havstad?S, Knoblich?B, Ressler?JA, Muzzin?AM, Tomlanovich?MC (2000) Critical care in the emergency department: a?physiologic assessment and outcome evaluation. Acad Emerg Med 7:1354-361
  37. Vincent?JL, Yagushi?A, Pradier?O (2002) Platelet function in sepsis. Crit Care Med 30:S313-17 CrossRef
  38. Yegenaga?I, Hoste?E, Van Biesen?W, Vanholder?R, Benoit?D, Kantarci?G, Dhondt?A, Colardyn?F, Lameire?N (2004) Clinical characteristics of patients developing ARF due to sepsis/systemic inflammatory response syndrome: results of a?prospective study. Am J Kidney Dis 43:817-24 CrossRef
  39. Lim?WS, van der Eerden?MM, Laing?R, Boersma?WG, Karalus?N, Town?GI, Lewis?SA, Macfarlane?JT (2003) Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 58:377-82 CrossRef
  40. Society BT. BTS Guidelines for the management of community acquired pneumonia in adults -2004 update. 2004 April 4, 2004 [cited 2006 October 1, 2006]; available from: http://www.brit-thoracic.org.uk/c2/uploads/MACAPrevisedApr04.pdf
  41. Shapiro?NI, Howell?M, Talmor?D (2005) A?blueprint for a?sepsis protocol. Acad Emerg Med 12:352-59 CrossRef
  
• 作者单位：Michael D. Howell (1)
  Michael Donnino (2)
  Peter Clardy (1)
  Daniel Talmor (3)
  Nathan I. Shapiro (2)
  
  1. Division of Pulmonary and Critical Care Medicine, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, KB-23, 330 Brookline Avenue, 02215, Boston, MA, USA
  2. Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
  3. Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
  

文摘

Objective To determine, in the early stages of suspected clinically significant infection, the independent relationship of the presenting venous lactate level to 28-day in-hospital mortality. Design Prospective, observational cohort study. Setting Urban, university tertiary-care hospital. Patients One thousand two hundred and eighty seven adults admitted through the emergency department who had clinically suspected infection and a?lactate measurement. Measurements and results Seventy-three [5.7% (95% CI 4.4-.9%)] patients died in the hospital within 28?days. Lactate level was strongly associated with 28-day in-hospital mortality in univariate analysis (p-lt;-.0001). When stratified by blood pressure, lactate remained associated with mortality (p-lt;-.0001). Normotensive patients with a?lactate level ≥-.0?mmol/l had a?mortality rate of 15.0% (6.0-4%). Patients with either septic shock or lactate ≥-.0?mmol/l had a?mortality rate of 28.3% (21.3-5.3%), which was significantly higher than those who had neither [mortality of 2.5% (1.6-.4%), p-lt;-.0001]. In a?model controlling for age, blood pressure, malignancy, platelet count, and blood urea nitrogen level, lactate remained strongly associated with mortality. Patients with a?lactate level of 2.5-.0?mmol/l had adjusted odds of death of 2.2 (1.1-.2); those with lactate?≥-.0?mmol/l had 7.1 (3.6-3.9) times the odds of death. The model had good discrimination (AUC--.87) and was well calibrated. Conclusions In patients admitted with clinically suspected infection, the venous lactate level predicts 28-day in-hospital mortality independent of blood pressure and adds significant prognostic information to that provided by other clinical predictors.