早期乳酸动态监测指标对严重脓毒症及脓毒症休克患者预后的评价  

Prognosis evaluation of early lactate dynamic monitoring index in severe sepsis and septic shock patients

作　　者：田慧艳 于斌[2] 胡振杰[2] 赵钗[2] 武新慧[2] 王澜涛[2] 

机构地区：[1]河北省计划生育科学技术研究院,石家庄市050071 [2]河北医科大学第四医院ICU

出　　处：《河北医药》2015年第10期1449-1453,共5页Hebei Medical Journal

基　　金：河北省医学科学研究重点课题计划(编号:20120368)

摘　　要：目的评价早期乳酸动态监测指标预测严重脓毒症及脓毒症休克患者预后的价值。方法选择2011年1月至2013年4月严重脓毒症或脓毒症休克患者115例,按治疗结局分为存活组和死亡组。所有患者入ICU后,尽早开始治疗,记录患者的年龄、性别、入ICU第1个24 h内APACHEⅡ评分、SOFA评分、Ramsay评分、医院住院时间、ICU住院时间、原发病发生情况、可疑感染源、28 d病死率;记录2组患者液体复苏不同时点的体温、心率、呼吸频率、中心静脉压（CVP）、平均动脉压（MAP）、尿量、中心静脉血氧饱和度（Scv O2）、Scv O2改变情况（Scv O2 variation）乳酸浓度、乳酸清除率等,评价各指标预测患者预后的准确性,分析影响患者预后的因素。结果 2例因入组后24 h内放弃治疗而排除本研究,所有患者至入院28 d共21例死亡。与存活组比较,死亡组APACHEⅡ评分及SOFA评分均升高,医院住院时间延长,T24时的乳酸浓度明显升高,T12、T24时的乳酸清除率明显下降（P〈0.05）。T24时乳酸清除率ROC曲线下面积最大（AUC=0.78,95%CI：0.56-0.82）,预测患者28 d预后的准确性最高,不同时点Scv O2、S cv O2 variation相关的ROC曲线下面积较小,预测患者28 d预后的准确性较差。多因素logistic回归分析结果显示,T24时的乳酸清除率和APACHEⅡ评分是患者存活的独立相关危险因素。结论入ICU后第1个24 h内的乳酸清除率与脓毒症患者预后的相关性最好,对预后的评价价值最高,即使超出入ICU最初6 h的最佳治疗窗后,脓毒症患者的治疗也应以乳酸清除率为指导。Objective To evaluating the prognostic value of early lactate dynamic monitoring index in severe sepsis and septic shock patients.Methods One hundred and fifteen patients with sever sepsis and septic shock admitted from January 2011 to April 2013 in ICU,were enrolled in the study.All the patients were divided into 2 groups according to the treatment outcome：survival group and death group.Management of all patient in ICU was performed during the first 24h hospitalization.The general condition and clinical characteristics on arrival in ICU,the changes of CVP,MAP,lactate levels and /or lactate clearance rate before and after the beginning of fluid resuscitation and the other related parameters during the therapy were observed and recorded.The assessment value for death prediction of these indexes was evaluated by the area under ROC curve （AUC）,and the factors of influencing patients’prognosis were analyzed by Logistic Regression.Results Two patients who gave up treatment within 24 hours were excepted from the study.Twenty-one patients died in the first 28 days.As compare with those in survival group,APACHEⅡscores and SOFA scores in death group were increased,length of stay in hospital was prolonged,lactate concentration was obviously increased at 24h after beginning of fluid resuscitation,lactate clearance rate was decreased at 12 h,24 h after beginning of fluid resuscitation in death group（P 〈0.05 ）.At 24h after beginning of fluid resuscitation,the area under ROC curve was the largest （AUC =0.78,95%CI：0.56 -0.82）,at different time points ScvO2 ,ScvO2 variation-related area under ROC curve was less,which suggested its accuracy for predicting patients’ 28-day prognosis was poor.Logistic regression analysis showed that the lactate clearance rate at 24h after beginning of fluid resuscitation and APACHE Ⅱ scores were the independent risk factors for patients’ survival.Conclusion The lactate clearance rate within the first 24h in ICU is closely correlated to the prognosis of patients with seps

关 键 词：乳酸 乳酸清除率 ScvO2 严重脓毒症 脓毒症休克 液体复苏 预后 

分 类 号：R631.4[医药卫生—外科学]