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1、Copyright c Society of Critical Care Medicine and Lippincott Williams XX 00 00 Key Words Surviving Sepsis Campaign sepsis mortality serum lactate A significant amount of evidence accumulated in the literature demonstrates that lactate is a useful predic tor of outcome in severe sepsis and septic sho
2、ck 1 3 Copyright 2014 by the Society of Critical Care Medicine and Lippincott Williams Gary S Phillips MAS5 Christa Schorr RN MSN6 R Phillip Dellinger MD6 Sean R Townsend MD7 Tiffany M Osborn MD MPH8 Konrad Reinhart MD9 Narendran Selvakumar MD4 Mitchell M Levy MD2 3 Copyright c Society of Critical C
3、are Medicine and Lippincott Williams 15 7 were regressed on 30 covariates using trun cated linear regression The four level risk factor was recreated and the GEE logistic regression model was re run All analyses were run using Stata 12 1 Stata Corporation College Station TX RESULTS Subjects Between
4、January 2005 and March 2010 the SSC database consisted of 28 150 patients at 218 hospitals median equal to 57 and a range of 20 471 subjects per hospital Each site contributed to the database between 1 and 21 quarters of data for a mean duration of 21 months median 20 months A consort diagram Fig 1
5、illustrates that 4 419 15 7 sub jects were missing serum lactate measurements The subjects were assumed to be missing completely at random because we failed to detect a difference in the in hospital mortal ity between those with a serum lactate and those without Mortality was 33 3 and 34 6 respectiv
6、ely p 0 104 In addition to determine whether a relationship exists between missing lactate and hypotension we tested whether the odds of hypotension changed over time for those missing and those without missing serum lactate values and found that the odds did not change with each site quarter increa
7、se p 0 076 and 0 422 respectively Removal of 4 419 subjects with missing lactate left 23 731 subjects for the analysis of continuous serum lactate by hypotension status and whether or not it was measured within 6 hours per SSC resuscitation bundle guidelines For the primary analysis we used only tho
8、se lactate values that were measured within 6 hours thus we removed 3 786 observations leaving 19 945 subjects for the primary analysis Patient Characteristics and Effect on Mortality The clinical characteristics of the 19 945 patients in the four different lactates groups who presented with presenc
9、e or absence of lactate greater than 4 mmol L in less than or equal to 6 hours with or without hypotension are detailed and com pared in Supplemental Table 1 Supplemental Digital Content 1 Patients who presented with lactate greater than 4 mmol L with hypotension showed a significantly higher mortal
10、ity of 44 5 compared with the other three groups who had a mortality of approximately 29 Hospital mortality differs across location where severe sep sis and septic shock were identified however in the adjusted regression analyses there were no statistically significant inter actions between the four
11、 groups and location Thus location was entered into the regression model as a confounder and not as an effect modifier No significant differences with respect to hospital length of stay the location of severe sepsis or septic shock identification or number of organ dysfunctions appear among the grou
12、ps The common sites of infection include pneumonia urinary tract and abdomen which comprised more than 80 of cases and with no significant differences among the lactate groups When reviewed by region Europe United States and South America the patient characteristics were found to be consis tent with
13、 the results above on the entire analysis population data not shown Similarly data reviewed by the location of severe sepsis and septic shock identification ED ward or ICU found results consistent with the entire population data not shown Unadjusted Lactates Associated With In Hospital Mortality Sta
14、tistical analysis on all 23 731 observations without miss ing lactate values from the SSC database showed a statistically significant increase in the odds of in hospital mortality in patients presenting with lactate values greater than 4 mmol L compared with those with lactate values less than or eq
15、ual to 2 greater than 2 to less than or equal to 3 and greater than 3 to less than or equal to 4 mmol L independent of hypotension status or when lactate was measured This analysis was deter mined using an unadjusted GEE population averaged logistic regression model Table 1 Even at lactate concentra
16、tions of 2 3 and 3 4 mmol L a significant increase appears in the odds of mortality in the hypotensive patients compared with lac tate less than 2 mmol L This association is consistent regard less of whether lactate is measured less than or equal to 6 or greater than 6 hours Figure 2 illustrates the linear increase in predicted in hospital mortality with increasing serum lactate measured on a continuous basis using a similar GEE model Whether the lactate was drawn in patients with severe sepsis
