A hypoperfusion context may aid to interpret hyperlactatemia in sepsis-3 septic shock patients: a proof-of-concept study
A hypoperfusion context may aid to interpret hyperlactatemia in sepsis-3 septic shock patients: a proof-of-concept study
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DOI：
10.1186/s13613-017-0253-x
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发表时间：
2017-03-09
影响因子：
8.1
通讯作者：
Hernandez, Glenn
中科院分区：
文献类型：
--
作者：
Alegria, Leyla;Vera, Magdalena;Hernandez, Glenn
背景：持续性高乳酸血症在感染性休克中尤其难以解释。除了灌注不足之外，肾上腺素驱动的乳酸产生和乳酸清除受损也是重要的原因。然而，遗憾的是，临床上对不同来源的高乳酸血症的认识并不常见，尽管某些患者存在过度复苏的风险，但仍采用相同的策略治疗患者。事实上，在非灌注不足相关的病例中进行额外的复苏可能会导致液体超负荷和血管活性药物的毒性。我们假设通过多模式灌注监测可以识别败血性休克患者的两种不同的临床模式。具有低灌注情况的高乳酸血症患者可能代表更严重的急性循环功能障碍，并且不存在低灌注情况最终与良好的结果相关。我们对初次复苏后持续性高乳酸血症的感染性休克患者数据库进行了回顾性分析。结果：我们通过存在 ScvO(2) < 70%，或 P(cv-a) CO2 >= 6 mmHg，或 CRT >= 4 s 与高乳酸血症一起定义低灌注情况。包括 90 名患者，其中 70 名表现出低灌注相关模式，20 名则没有。尽管乳酸值在基线时相当（4.8 +/- 2.8 与 4.7 +/- 3.7 mmol/L），但灌注不足的患者表现出更严重的循环功能障碍，需要更高的升压药，并且有机械通气天数更长、入住 ICU 和更多抢救治疗的趋势。 20 名没有低灌注背景的高乳酸血症患者中只有 1 名死亡 (5%)，而 70 名患有低灌注相关高乳酸血症的患者中有 11 名死亡 (16%)。结论：根据低灌注背景，可以识别高乳酸血症败血性休克患者的两种不同临床模式。高乳酸血症加上低 ScvO(2) 或高 P(cv-a) CO2 或高 CRT 值的患者表现出更严重的循环功能障碍。这为开展进一步的前瞻性研究提供了一个起点，以确认这种方法是否可以带来更具选择性的复苏策略。
Background: Persistent hyperlactatemia is particularly difficult to interpret in septic shock. Besides hypoperfusion, adrenergic-driven lactate production and impaired lactate clearance are important contributors. However, clinical recognition of different sources of hyperlactatemia is unfortunately not a common practice and patients are treated with the same strategy despite the risk of over-resuscitation in some. Indeed, pursuing additional resuscitation in non-hypoperfusion- related cases might lead to the toxicity of fluid overload and vasoactive drugs. We hypothesized that two different clinical patterns can be recognized in septic shock patients through a multimodal perfusion monitoring. Hyperlactatemic patients with a hypoperfusion context probably represent a more severe acute circulatory dysfunction, and the absence of a hypoperfusion context is eventually associated with a good outcome. We performed a retrospective analysis of a database of septic shock patients with persistent hyperlactatemia after initial resuscitation.Results: We defined hypoperfusion context by the presence of a ScvO(2) < 70%, or a P(cv-a) CO2 >= 6 mmHg, or a CRT >= 4 s together with hyperlactatemia. Ninety patients were included, of whom seventy exhibited a hypoperfusion-related pattern and 20 did not. Although lactate values were comparable at baseline (4.8 +/- 2.8 vs. 4.7 +/- 3.7 mmol/L), patients with a hypoperfusion context exhibited a more severe circulatory dysfunction with higher vasopressor requirements, and a trend to longer mechanical ventilation days, ICU stay, and more rescue therapies. Only one of the 20 hyperlactatemic patients without a hypoperfusion context died (5%) compared to 11 of the 70 with hypoperfusion-related hyperlactatemia (16%).Conclusions: Two different clinical patterns among hyperlactatemic septic shock patients may be identified according to hypoperfusion context. Patients with hyperlactatemia plus low ScvO(2), or high P(cv-a) CO2, or high CRT values exhibited a more severe circulatory dysfunction. This provides a starting point to launch further prospective studies to confirm if this approach can lead to a more selective resuscitation strategy.