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美國一項新研究發現，急診部對疑似敗血症患者採用現場血乳酸點測技術，顯著縮短了檢測及靜脈注射液體的等待時間。此外，此技術還成功降低了患者的死亡率及重症監護室收治率，改善了敗血症的急救效果。
ED bedside point-of-care lactate in patients with suspected sepsis is associated with reduced time to iv fluids and mortality
急診床邊即時乳酸測定在疑似敗血症患者中與縮短靜脈輸液時間及降低死亡率相關
Singer AJ, Taylor M, LeBlanc D, Williams J, Thode HC Jr. ED bedside point-of-care lactate in patients with suspected sepsis is associated with reduced time to iv fluids and mortality. Am J Emerg Med. 2014;32(9):1120-1124. doi:10.1016/j.ajem.2014.06.027
Abstract
Objective
Early recognition and treatment of sepsis improves outcomes. We determined the effects of bedside point-of-care (POC) lactate measurement on test turnaround time, time to administration of IV fluids and antibiotics, mortality, and ICU admissions in adult ED patients with suspected sepsis. We hypothesized that bedside lactate POC testing would reduce time to IV fluids and antibiotics.
Methods
We compared 80 ED patients with suspected sepsis and a lactate level of 2 mmol/L or greater before and 80 similar patients after introduction of POC lactate measurements. Groups were compared with Χ2 and Mann Whitney U tests. A sample size of 80 patients in each group had 85% power to detect a 30-minute difference in time to IV fluids or antibiotics.
Results
Study groups were similar in age, gender, baseline lactate levels, sepsis severity, and Sequential Organ Failure Assessment (SOFA) scores. Introduction of POC lactate was associated with significant reductions in test turnaround time (34 [26-55] vs. 122 [82-149] minutes; P < 0.001), time to IV fluids (55 [34-83] vs. 71 [42-110] minutes; P = 0.03), mortality (6% vs. 19%; P = 0.02), and ICU admissions (33% vs. 51%, P = 0.02), but not time to IV antibiotics (89 [54-156] vs. 88 [60-177] minutes; P = 0.35).
Conclusions
Implementation of bedside POC lactate measurement in adult ED patients with suspected sepsis reduces time to test results and time to administration of IV fluids but not antibiotics. A significant reduction in mortality and ICU admissions was also demonstrated, which is likely due, at least in part, to POC testing.
摘要
目標
早期識別和治療敗血症能改善患者結果。我們確定了在成人急診患者中，床邊即時乳酸測定對測試週轉時間、靜脈輸液和抗生素的施用時間、死亡率及入住加護病房的影響。我們假設床邊乳酸即時測試將縮短靜脈輸液和抗生素的施用時間。
方法
我們比較了在引入即時乳酸測定前後，80 名急診疑似敗血症且乳酸水平達 2 mmol/L 或以上的患者。組間比較使用卡方檢驗和曼-惠特尼 U 檢驗。每組 80 名患者的樣本量有 85% 的把握檢測到靜脈輸液或抗生素施用時間的 30 分鐘差異。
結果
研究組在年齡、性別、基線乳酸水平、敗血症嚴重程度和序列器官衰竭評分（SOFA）方面相似。引入即時乳酸測定後，測試週轉時間顯著縮短（34 [26-55] 分鐘對比 122 [82-149] 分鐘；P < 0.001），靜脈輸液時間縮短（55 [34-83] 分鐘對比 71 [42-110] 分鐘；P = 0.03），死亡率降低（6% 對比 19%；P = 0.02），入住加護病房率下降（33% 對比 51%；P = 0.02），但靜脈抗生素施用時間無顯著差異（89 [54-156] 分鐘對比 88 [60-177] 分鐘；P = 0.35）。
結論
在成人急診疑似敗血症患者中實施床邊即時乳酸測定能縮短測試結果時間和靜脈輸液施用時間，但對抗生素施用時間無影響。同時顯示出顯著降低的死亡率和入住加護病房率，這至少部分歸功於即時測試。
引言
敗血症被定義為對感染的全身性炎症反應。每年美國急診部門約有 1,000,000 例敗血症病例，死亡率範圍在 20% 到 50% 之間 [1], [2], [3]。早期識別敗血症可啟動目標導向的治療，如抗生素和靜脈輸液，以減少發病率和死亡率 [4]。延遲啟動抗生素治療與死亡率增加相關 [5]。根據證據，多個專業學會已發布共識指導方針，對敗血症的評估和管理提出建議 [6]。多項研究表明，乳酸水平可預測敗血症患者的預後 [7], [8], [9]。因此，指導方針建議早期測量乳酸水平，以識別組織灌流不足且風險最大的患者，特別是尚未出現低血壓的隱性休克患者 [6]。依賴早期乳酸測量的一個主要限制是與中央實驗室測試相關的延遲。使用手持精準設備進行床邊即時測試有可能顯著縮短測試週轉時間，更重要的是縮短治療週轉時間，這表示從訂單到結果可供臨床醫生使用以作出治療決策的時間。幾項對急診疑似敗血症患者的觀察研究發現，相較於中央實驗室測試，乳酸的床邊即時測量既可行又準確 [10], [11]。然而，這些研究並未比較測試週轉時間或確定即時測試的臨床影響。
本研究旨在確定引入床邊乳酸即時測試是否能縮短乳酸測量時間，從而縮短重度敗血症的識別時間及靜脈輸液和抗生素治療的啟動時間。我們假設，與中央實驗室測試相比，床邊乳酸即時測試將縮短急診敗血症患者靜脈輸液和抗生素施用的時間。
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