Аннотация
Актуальность. Уровень лактата и центральная венозная сатурация крови (ScvO2) отражают гипоперфузию тканей, но на каждый показатель влияет множество дополнительных факторов. Эти дополнительные факторы различны для лактата и ScvO2. Цель исследования. Мы предполагаем, что одновременная оценка уровня лактата и ScvO2 может дать более ценную информацию, чем измерения показателей по отдельности. В частности, мы стремились определить, обладает ли лактат различными характеристиками и различной прогностической ценностью при разных уровнях ScvO2. Материал и методы. Мы провели ретроспективный анализ экспериментальной и контрольной когорты пациентов с сепсисом, у которых уровень лактата и ScvO2 измеряли в течение первых 4 ч после поступления в ОИТ и через 12 ч после реанимации. Пациенты были сгруппированы по критериям: 1) ScvO2 < 60 %; 2) 60 % ≤ ScvO2 < 80 %; 3) ScvO2 ≥ 80 %. Результаты. Уровень лактата отрицательно коррелировал с ScvO2 в группе ScvO2 < 60 % в обеих когортах, но в других группах ScvO2 корреляции выявлено не было. Используя анализ ROC-кривых в экспериментальной когорте, установлено, что в группе ScvO2 ≥ 80 % уровень лактата прогнозировал 28-дневную смертность с площадью под кривой 0,94 и оптимальным пороговым значением лактата 3,0 ммоль/л. С учетом этого порога 28-дневная смертность в группе ScvO2 ≥ 80 % составила 32,7 %. Заключение. Уровень лактата имеет разные характеристики и прогностическую ценность при разных уровнях ScvO2. При ScvO2 < 60 % корреляция между уровнем лактата и ScvO2 связана со степенью гипоксии. В группе ScvO2 ≥ 80 % уровень лактата > 3,0 ммоль/л является прогностическим фактором смертности.
Библиографические ссылки
- Evans L., Rhodes A., Alhazzani W., et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021; 2: 1–67. DOI: 10.1007/s00134-021-06506-y
- Kraut J.A., Madias N.E. Lactic acidosis. N Engl J Med. 2014; 371(24): 2309–19. DOI: 10.1056/NEJMra1309483
- Reid M. Central venous oxygen saturation: analysis, clinical use and effects on mortality. Nurs Crit Care. 2013; 18(5): 245–50. DOI: 10.1111/nicc.12028
- Walton R.A.L., Hansen B.D. Venous oxygen saturation in critical illness. J Vet Emerg Crit Care (San Antonio). 2018; 28(5): 387–97. DOI: 10.1111/vec.12749
- O’Dell E., Tibby S.M., Durward A., et al. Hyperchloremia is the dominant cause of metabolic acidosis in the postresuscitation phase of pediatric meningococcal sepsis. Crit Care Med. 2007; 35: 2390–4. DOI: 10.1097/01.CCM.0000284588.17760.99
- Park M., Azevedo L.C., Maciel A.T., et al. Evolutive standard base excess and serum lactate level in severe sepsis and septic shock patients resuscitated with early goal-directed therapy: Still outcome markers? Clinics. 2006; 61: 47–52. DOI: 10.1590/s1807-59322006000100009
- Smith I., Kumar P., Molloy S., et al. Base excess and lactate as prognostic indicators for patients admitted to intensive care. Intensive Care Med. 2001; 27: 74–83. DOI: 10.1007/s001340051352
- Vincent J.L., De Backer D. Circulatory shock. N Engl J Med. 2013; 369: 1726–34. DOI: 10.1056/NEJMra1208943
- Casserly B., Phillips G.S., Schorr C., et al. Lactate measurements in sepsis-induced tissue hypoperfusion: results from the Surviving Sepsis Campaign database. Crit Care Med. 2015; 43: 567–73. DOI: 10.1097/CCM.0000000000000742
- Zhang Z., Chen K., Ni H., et al. Predictive value of lactate in unselected critically ill patients: an analysis using fractional polynomials. J Thorac Dis. 2014; 6: 995–1003. DOI: 10.3978/j.issn.2072-1439.2014.07.01
- Ryoo S.M., Ahn R., Shin T.G., et al. Lactate normalization within 6 hours of bundle therapy and 24 hours of delayed achievement were associated with 28-day mortality in septic shock patients. PLoS One. 2019; 14(6): e0217857. DOI: 10.1371/journal.pone.0217857
- Nichol A.D., Egi M., Pettila V., et al. Relative hyperlactatemia and hospital mortality in critically ill patients: a retrospective multi-centre study. Crit Care. 2010; 14: R25. DOI: 10.1186/cc8888
- Levy M.M., Evans L.E., Rhodes A. The Surviving Sepsis Campaign Bundle: 2018 Update. Crit Care Med. 2018; 46(6): 997–1000. DOI: 10.1097/CCM.0000000000003119
- Jansen T.C., Bommel J.V., Schoonderbeek F.J., et al. LACTATE study group. Early lactate-guided therapy in intensive care unit patients: A multicenter, open-label, randomized controlled trial. Am J Respir Crit Care Med. 2010; 182: 752–61. DOI: 10.1164/rccm.200912-1918OC
- Jones A.E., Shapiro N.I., Trzeciak S., et al. Emergency Medicine Shock Research Network (EMShockNet) Investigators. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: A randomized clinical trial. JAMA. 2010; 303: 739–46. DOI: 10.1001/jama.2010.158
- Rivers E.P., Ander D.S., Powell D. Central venous oxygen saturation monitoring in the critically ill patient. Curr Opin Crit Care. 2001; 7:204–11. DOI: 10.1097/00075198-200106000-00011
- Muckart D.J, Bhagwanjee S. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference definitions of the systemic inflammatory response syndrome and allied disorders in relation to critically injured patients. Crit Care Med. 1997; 25(11): 1789–95. DOI: 10.1097/00003246-199711000-00014
- Walley K.R. Use of Central Venous Oxygen Saturation to Guide Therapy. Am J Respir Crit Care Med. 2011; 184(5): 514–20. DOI: 10.1164/rccm.201010-1584CI
- Bellomo R., Reade M.C., Warrillow S.J. The pursuit of a high central venous oxygen saturation in sepsis: growing concerns. Crit Care. 2008; 12(2): 130. DOI: 10.1186/cc6841
- Rivers E., Nguyen B., Havstad S., et al. Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001; 345(19):1368–77. DOI: 10.1056/NEJMoa010307
- Jones A.E., Shapiro N.I., Trzeciak S., et al. Emergency Medicine Shock Research Network I: lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010; 303: 739–46. DOI: 10.1001/jama.2010.158
- Peake S.L., Delaney A., Bailey M., et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014; 371: 1496–506. DOI: 10.1056/NEJMoa1404380
- Mouncey P.R., Osborn T.M., Power G.S., et al. Trial of early, goaldirected resuscitation for septic shock. N Engl J Med. 2015; 372:1301–11. DOI: 10.1056/NEJMoa1500896
- Yealy D.M., Kellum J.A., Huang D.T., et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014; 370: 1683–93. DOI: 10.1056/NEJMoa1401602
- Singer M., Deutschman C.S., Seymour C.W., et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016; 23; 315(8): 801–10. DOI: 10.1001/jama.2016.0287
- Bracht H., Hänggi M., Jeker B., et al. Incidence of low central venous oxygen saturation during unplanned admissions in a multidisciplinary intensive care unit: an observational study. Critical Care. 2007; 11: R2. DOI: 10.1186/cc5144
- Textoris J., Fouché L., Wiramus S., et al. High central venous oxygen saturation in the latter stages of septic shock is associated with increased mortality. Crit Care. 2011; 26; 15(4): R176. DOI: 10.1186/cc10325
- Lee Y.K., Hwang S.Y., Shin T.G., et al. Prognostic value of lactate and central venous oxygen saturation after early resuscitation in sepsis patients. PLoS One. 2016; 11(4): e0153305. DOI: 10.1371/journal.pone.0153305
- Casserly B., Phillips G.S., Schorr C., et al. Lactate measurements in sepsis-induced tissue hypoperfusion: results from the Surviving Sepsis Campaign database. Crit Care. 2015; 43: 567–573. DOI: 10.1097/CCM.0000000000000742
- Puskarich M.A., Trzeciak S., Shapiro N.I., et al. Whole blood lactate kinetics in patients undergoing quantitative resuscitation for severe sepsis and septic shock. Chest. 2013; 143: 1548–1553. DOI: 10.1378/chest.12-0878
- Suetrong B., Walley K.R. Lactic Acidosis in Sepsis: It’s not all anaerobic implications for diagnosis and management. CHEST. 2016; 149(1): 252–261. DOI: 10.1378/chest.15-1703
- Rivers E.P., Elkin R., Cannon C.M. Counterpoint: should lactate clearance be substituted for central venous oxygen saturation as goals of early severe sepsis and septic shock therapy? No. Chest. 2011; 140: 1408–1413. DOI: 10.1378/chest.11-2563
- Hernandez G., Castro R., Romero C., et al. Persistent sepsis-induced hypotension without hyperlactatemia: is it really septic shock? J Crit Care. 2011; 26: e439– e414. DOI: 10.1016/j.jcrc.2010.09.007
- Omar S., Burchard A.T., Lundgren A.C., et al. The relationship between blood lactate and survival following the use of adrenaline in the treatment of septic shock. Anaesth Intensive Care. 2011; 39(3): 449–455. DOI: 10.1177/0310057X1103900316
- Rowan K.M., Angus D.C., Bailey M., et al. Early, Goal-Directed Therapy for Septic Shock — A Patient-Level Meta-Analysis. N Engl J Med. 2017; 376(23): 2223–2234. DOI: 10.1056/NEJMoa1701380
- Pope J.V., Jones A.E., Gaieski D.F., et al. Multicenter study of central venous oxygen saturation (ScvO2) as a predictor of mortality in patients with sepsis. Ann Emerg Med. 2010; 55(1): 40–46.e1. DOI: 10.1016/j.annemergmed.2009.08.014
- Shin T.G., Jo I.J., Hwang S.Y., et al. Comprehensive interpretation of central venous oxygen saturation and blood lactate levels during resuscitation of patients with severe sepsis and septic shock in the emergency department. SHOCK. 2016; 45(1): 4–9. DOI: 10.1097/SHK.0000000000000466
- Bisarya R., Shaath D., Pirzad A., et al. Serum lactate poorly predicts central venous oxygen saturation in critically ill patients: a retrospective cohort study. J Intensive Care. 2019; 7:47. DOI: 10.1186/s40560-019-0401-5
- Roberts J.K., Disselkamp M., Yataco A.C. Oxygen Delivery in Septic Shock. Ann Am Thorac Soc. 2015; 12(6): 952–955. DOI: 10.1513/AnnalsATS.201501-069CC
- Joshi R., de Witt B., Mosier J.M. Optimizing oxygen delivery in the critically ill: the utility of lactate and central venous oxygen saturation (ScvO2) as a roadmap of resuscitation in shock. The Journal of emergency medicine. 2014; 47(4): 493–500. DOI: 10.1016/j.jemermed.2014.06.016
- Nguyen H.B., Rivers E.P., Knoblich B.P., et al. Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med. 2004; 32 (8): 1637–42. DOI: 10.1097/01.ccm.0000132904.35713.a7
- Vallet B., Pinsky M.R., Cecconi M. Resuscitation of patients with septic shock: please ‘mind the gap’! Intensive Care Med. 2013; 39:1653–5. DOI: 10.1007/s00134-013-2998-5
- Vallée F., Vallet B., Mathe O., et al. Central venous-to-arterial carbon dioxide difference: an additional target for goal-directed therapy in septic shock? Intensive Care Med. 2008; 34: 2218–25. DOI: 10.1007/s00134-008-1199-0
- Ospina-Tascon G.A., Bautista-Rincon D.F., Umaña M., et al. Persistently high venous-to-arterial carbon dioxide differences during early resuscitation are associated with poor outcomes in septic shock. Crit Care. 2013; 17: R294. DOI: 10.1186/cc13160
- Mesquida J., Gruartmoner G., Espinal C., et al. Central venous-to-arterial carbon dioxide difference combined with arterial-to-venous oxygen content difference is associated with lactate evolution in the hemodynamic resuscitation process in early septic shock Crit Care. 2015; 19(1): 126. DOI: 10.1186/s13054-015-0858-0

Это произведение доступно по лицензии Creative Commons «Attribution-NonCommercial-ShareAlike» («Атрибуция — Некоммерческое использование — На тех же условиях») 4.0 Всемирная.
Copyright (c) 2022 ВЕСТНИК ИНТЕНСИВНОЙ ТЕРАПИИ имени А.И. САЛТАНОВА