摘要
目的评估血乳酸参数, 包括初始乳酸浓度(LACinitial)、乳酸峰值浓度(LACpeak)、乳酸达峰时间(LACtimetopeak)、乳酸负荷面积(LACarea)以及6 h和12 h乳酸清除率(LC6h和LC12 h), 在老年脓毒症患者中的预后预测价值并探索其最佳应用阈值。方法回顾性筛选了2008-2019年入住贝斯以色列女执事医疗中心(Beth Israel Deaconess Medical Center)重症监护室(ICU)的老年脓毒症患者, 收集患者的一般信息以及入院后24 h内的生命体征、实验室指标, 并继续采集或计算急性生理学评分Ⅲ(APSⅢ)、序贯器官功能衰竭评分(SOFA)和牛津急性疾病严重度评分(OASIS)。记录结局变量包括入住ICU起28 d死亡率、住ICU时间、总住院时间以及机械通气时间。比较存活组和非存活组组间血乳酸参数的差异, 根据28 d死亡率绘制受试者特征工作曲线(ROC), 计算曲线下面积(AUC), 分析比较各乳酸参数的预测效能, 并依据各乳酸参数最佳截断值进行Kaplan-Meier生存曲线分析。结果共纳入4 773例老年脓毒症患者, 其中1 166例(24.4%)在28 d内死亡。相较于存活组, 非存活组具有较高的LACinitial[3.30(2.40, 5.30)比2.70(2.20, 3.50)mmol/L, Z=-13.047, P<0.001]、LACarea[36.40(18.28, 63.00)比14.80(7.40, 27.30)mmol·L^(-1)·h, Z=-10.298, P<0.001]、LACpeak[4.00(2.80, 6.70)比3.10(2.50, 4.10)mmol/L, Z=-15.573, P<0.001]、LACtimetopeak[7.00(3.00, 15.00)比4.00(2.00, 8.00)h, Z=-13.084, P<0.001], 以及较低的LC6h[0.06(-0.21, 0.29)比0.14(-0.22, 0.39), Z=2.966, P=0.003]、LC12 h[0.12(-0.21, 0.42)比0.29(-0.09, 0.50), Z=5.638, P<0.001]。在4 773例老年脓毒症患者中, 入ICU 24 h内, 按降序排列的各乳酸参数对28 d死亡率预测的AUC分别为LACpeak[0.651(0.632, 0.670)]、LACinitial[0.627(0.607, 0.646)]、LACtimetopeak[0.626(0.607, 0.646)]和LACarea[0.590(0.569, 0.610)]。其中, LACarea在排除了等于0的异常情况后, 其AUC提升为LACarea2[0.739(0.714, 0.764)]。有1 217例患者可计算6 h和12 h乳酸清除率, 其AUC分别为LC6h[0.515(0.481, 0.548)]、LC12 h[0.568(0.534, 0.603)]。此外, 在1 042例LACinitial>2 mmol/L的老年脓毒症人群中, LC的AUC则表现为LC6h[0.560(0.524, 0.596)]、LC12 h[0.614(0.577, 0.651)]。根据ROC曲线分析计算得出LACinitial、LACpeak、LACtimetopeak、LACarea、LC6h、LC12 h的最佳截断值依次为3.55 mmol/L、4.45 mmol/L、7.50 h、28.65 mmol·L^(-1)·h、0.304、0.272, 据此将研究对象分为达到最佳截断值组和未达到组, Kaplan-Meier生存曲线可明显区分两组且差异均有统计学意义(均P<0.05)。结论针对老年脓毒症患者28 d死亡率的预测效能, LACarea最佳, LACpeak、LACinitial、LACtimetopeak居中, 乳酸清除率虽最差但可通过调整适用人群而改善其效能。
Objective To evaluate various blood lactate parameters in elderly patients with sepsis for prognostic prediction and exploration of optimal threshold values.The parameters include initial lactate concentration(LACinitial),lactate peak concentration(LACpeak),lactate peak time(LACtimetopeak),lactate accumulation area(LACarea),and 6-hour and 12-hour lactate clearance rates(LC_6 h and LC_12 h).Methods This study conducted a retrospective screening of elderly patients with sepsis who were admitted to the intensive care unit(ICU)of the Beth Israel Deaconess Medical Center between 2008 and 2019.The study collected general information of the patients,as well as vital signs and laboratory indicators within 24 hours after admission.Additionally,the APS Ⅲ score,SOFA score,and OASIS score were continuously collected or calculated.The outcome variables examined were 28-day mortality from ICU admission,ICU length of stay,hospital length of stay,and mechanical ventilation time.The study compared the blood lactate parameters between the survival group and the nonsurvival group,and calculated the odds ratio(OR).A receiver operating characteristic curve(ROC curve)was plotted to analyze and compare the predictive performance of each lactate parameter based on 28-day mortality.The area under the curve(AUC)was calculated.Additionally,Kaplan-Meier survival curves were analyzed using the cutoff value of each lactate parameter.ResultsA total of 4773 elderly sepsis patients were included in the study.Among them,1166(24.4%)died within 28 days.The nonsurvival group had significantly higher levels of LACinitial[3.30(2.40,5.30)us.2.70(2.20,3.50)mmol/L,Z=-13.047,P<0.001,LACarea[36.40(18.28,63.00)vs.14.80(7.40,27.30)mmol.L=1.h.Z=-10.298,P<0.001J,LACpeak[4.00(2.80,6.70)us.3.10(2.50,4.10)mmol/L,Z=-15.573,P<0.001],and LACtimetopeak[7.00(3.00,15.00)us.4.00(2.00,8.00)h,Z=-13.084,P<0.001].Additionally,the nonsurvival group had significantly lower levels of LC_6 h[0.06(-0.21,0.29)us.0.14(-0.22,0.39),Z=2.966,P=0.003]andLC_12h[0.12(-0.21.0.42)us.0.29(-0.09,0.50),Z=5.638,P<0.001].In this study involving 4773 elderly sepsis icases,the lactate parameters were evaluated for their ability to predict death within 24 hours of ICU admission.The area under the curve(AUC)values,presented in descending order,were as follows:LACpeak[0.651(0.632,0.670)],LACinitialL0.627(0.607,0.646)],LACtimetopeak[0.626(0.607,0.646)],and LACarea[0.590(0.569,0.610)].After excluding the cases where the LACarea was 0,the AUC increased to LACarea2[0.739(0.714,0.764)].A total of 1217 patients had their lactate clearance rates at 6 hours and 12 hours calculated,with AUCs of LC_6 h[0.515(0.481,0.548)]and LC_12 h[0.568(0.534,0.603)J,respectively.Furthermore,among 1042 elderly sepsis patients with LACinitial>2 mmol/L,the AUCs of LC were LC_6 h[0.560(0.524,0.596)]and LC_12 h[0.614(0.577,0.651)].The optimal cutoff values for LACinitial,LACpeak,LACtimetopeak,LACarea,LC_6 h,and LC_12 h,calculated from ROC curve analysis,were 3.55 mmol/L,4.45 mmol/L,7.50 h,28.65 mmol·L^(-1)·h,0.304 and 0.272,respectively.The study population was divided into two groups based on whether they achieved the optimal cutoff value or not.The Kaplan-Meier survival curve showed a significant and distinguishable difference between these two groups(all P<o.05).Conclusions In the prediction of 28-day mortality in elderly sepsis patients,LACarea was found to be the most effective indicator.LACpeak,LACinitial,and LACtimetopeak also showed acceptable predictive capabilities.On the other hand,LC performed the worst among the indicators,but its performance could potentially be enhanced by adjusting the applicable population.
作者
邸晨义
任炳魁
陈思莹
常志刚
Di Chenyi;Ren Bingkui;Chen Siying;Chang Zhigang(Department of Critical Care Medicine,Beijing Hospital,National Center of Gerontology,Institute of Geriatric Medicine,Chinese Academy of Medical Sciences,Beijing 100730,China)
出处
《中华老年医学杂志》
CAS
CSCD
北大核心
2023年第12期1435-1441,共7页
Chinese Journal of Geriatrics
基金
北京市自然科学基金面上项目(7232139)
吴阶平医学基金会临床科研专项资助基金(320.6750.2022-26-3)。
关键词
乳酸
脓毒症
乳酸清除率
乳酸负荷面积
Lactic acid
Sepsis
Lactate clearance
Lactateacct mulation area
