Prognostic value of difference between peripheral venous and arterial lactate in patients with septic shock：a prospective pilot study
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摘要:
目的：探讨外周静脉-动脉血乳酸差值对感染性休克患者预后的预测价值。方法：采用前瞻性研究方法，选择2017年5月—2018年5月南京中医药大学附属中西医结合医院重症医学科收治的感染性休克患者，测定患者入院时及早期复苏6 h后动脉及外周静脉血血气分析，记录患者动脉血乳酸（A-lac）及外周静脉血乳酸（V-Lac），计算患者外周静脉-动脉血乳酸差值（ΔLac），根据患者28 d预后将患者分为存活组及死亡组，采用多因素Logistic回归分析患者死亡的危险因素，并通过受试者工作特征曲线（ROC）评价各项指标变化，预测患者预后。结果：共入选59例感染性休克复苏达标患者，28 d存活34例，死亡25例。与存活组比较，死亡组患者急性生理与慢性健康（acute physiology and chronic health evaluation，APCHE） Ⅱ评分及序贯器官衰竭评分（sequential organ failure assessment，SOFA）明显升高（P < 0.05），患者入院时A-Lac和V-Lac明显升高（P < 0.05），早期复苏6 h后V-Lac和ΔLac明显升高（P < 0.05）。多因素Logistic回归分析显示，复苏后ΔLac是患者28 d生存率的独立预后因素（P=0.005）。ROC曲线分析显示，早期复苏6 h后ΔLac的ROC曲线下面积（AUC）最大，为0.838（OR=74.107，P < 0.001），最佳临界值为0.65 mmol/L时，预测患者28 d死亡的敏感度为76.0%，特异度为85.3%。结论：外周静脉-动脉血乳酸差值与感染性休克患者预后相关，可作为评估感染性休克患者28 d生存率的独立预后指标。
Abstract:
Objective：To evaluate the value of the difference between peripheral venous and arterial lactate level for the prognosis of patients with septic shock after early resuscitation. Methods：Patients with septic shock in the Department of Critical Care Medicine，Affiliated Hospital of Integration of Chinese and Western Medicine，Nanjing University of Chinese Medicine from May 2017 to May 2018 were enrolled in this prospective observational study. Patients were divided into two groups according to the 28-day mortality. Peripheral venous and arterial blood samples were withdrawn simultaneously and analyzed immediately at the bedside on admission and after 6 h-bundles of treatments. Peripheral venous lactate concentration（V-Lac）and arterial lactate concentration（A-Lac）were recorded，while the difference between V-Lac and A-Lac（ΔLac） was calculated. Multivariate logistic regression analysis was performed to select possible risk factors for 28-day mortality，and the receiver operating characteristic curve（ROC） was plotted to assess the prognostic value for 28-day mortality. Results：Fifty-nine patients were enrolled. Thirty-four patients survived and twenty-five patients died during the 28-day period. Compared with the survivor group，acute physiology and chronic health evaluation Ⅱ score（APACHE Ⅱ）and acute physiology and chronic health evaluation Ⅱ score（SOFA）were significantly higher in the non-survivor group（P < 0.05）. In the non-survivor group，A-Lac and V-Lac were significantly higher at admission（P < 0.05），and V-Lac and ΔLac were significantly higher after 6 h-bundles of treatments（P < 0.05）. Multivariate logistic regression analysis showed that ΔLac after 6 h-bundles of treatments（OR=74.107，P=0.005）was the independent risk factors for 28-day mortality. It was shown by ROC curve analysis that the maximum area under the ROC curve（AUC）of ΔLac was 0.838（P < 0.001）.When the best cut-off value was 0.65 mmol/L as a predictor of 28-day mortality，the sensitivity was 76.0% and the specificity was 85.3%. Conclusion：The presence of ΔLac after the early resuscitation of septic shock is associated with worse outcomes. It can be used to gauge the severity of tissue hypofusion and to estimate poor outcome of patients with septic shock.
