Acil serviste şok tanısı alan hastalarda laboratuvar değerlerinin ve monitör parametrelerinin prognostik değerlerinin incelenmesi
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Tarih
2016
Yazarlar
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Yayıncı
Ege Üniversitesi, Tıp Fakültesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
AMAÇ: Bu çalışmada acil servise başvurusunda veya izleminde şok tanısı alan hastaların prognoz ve klinik özelliklerini belirleyerek; şok hasta takibinde ve mortaliteyi öngörmede etkin monitör parametreleri ve kan değerleri arasındaki ilişkiyi saptamak ve standart yaşamsal parametrelere ek olarak yeni ve non-invazif, kolay ve çabuk elde edilebilir bir parametre olan EtCO2 ölçümünün klinik değerliliği konusunda bilgi edinebilmek amaçlandı. YÖNTEM: Prospektif kesitsel bir çalışma olarak tasarlanan çalışmamızda Ege Üniversitesi Hastanesi Acil Servisine başvuran ve şok tanısı alan hastalarda EtCO2 ölçümü yapılan hastalar çalışmaya alındı. Hastaların sistolik ve diastolik kan basıncı, nabız, solunum sayısı, ateş, saturasyon ve entübe hastalarda makrostream yöntem ile spontan soluyan hastalarda sidestream yöntem ile EtCO2 değerleri ölçüldü. Hastaların kan gazı ve laboratuar değerleri kaydedildi ve 2.saatte kontrol vital bulguları ile EtCO2 ve laktat değerleri ölçüldü. Tüm hastalarda SOFA skorları hesaplandı ve kaydedildi. Hastaların 1.gün mortalite oranları, yatış veya taburculuk durumları kaydedildi. Hastane yatışı ve taburculukları sonrası da takip edilerek 30 günlük mortalite oranları incelendi. BULGULAR: Şok tanısı alıp EtCO2 ölçümü yapılan 300 hasta çalışmaya alındı. Hastaların yaş ortalaması 68±16 saptandı. Hastaların % 46,3'ü erkek, %53,7'si kadındı. Hastaların ortalama EtCO2 değeri 21,4±6,4 mmHg saptandı. İlk 24 saatte mortalite oranı %16,7 iken 30gün içinde ölen hasta oranı %56,7 saptandı. İlk 24 saatte ölen hastalarda EtCO2 ortalaması 17,2 (%95 GA:18,4-20,5) saptanırken; sağkalan hastalarda 22,3 (%95 GA:23,4-25,2) saptanmış olup iki grup arasında anlamlı fark saptandı (p<0,001). Monitör parametrelerinden ile 1.gün mortaliteyi öngörme gücü ROC analizi ile karşılaştırıldığında ROC eğrisi altında kalan alan en fazla EtCO2 (AUC:0,76; %95 GA:0,66-084; p<0,001) için saptandı. Hastalarda kontrol 2.saatte ölçülen EtCO2 için ROC eğrisi altında kalan alan daha yüksek saptanmıştır. (AUC:081; %95 GA:0,73-0,90; p<0,001) . 30 gün içinde mortal seyreden hastalarda da EtCO2 anlamlı saptanmış olup (p<0,001); ROC eğrisi altında kalan alan 1. Gün mortalite ile benzer saptanmıştır. EtCO2 için ROC analizi ve %50 ortalama persentil hesaplanarak 21 mmHg cut-off değer olarak alındı. EtCO2 değeri 21 mmHg ve altında olan hastalar için sensitivite %78,0; spesifite %52,8 ve negatif prediktif değer %92,3 bulundu. Düşük EtCO2 değerlerinin 1.gün mortaliteyi belirlemede rölatif riski 3,42 saptandı. EtCO2 ile laktat arasında ters yönde korelasyon bulundu (p=0,026). EtCO2; bikarbonat (p<0,001) ve baz açığı(p<0,001) ile korele bulunurken; pH ile korele bulunmadı (p=0,349). TARTIŞMA: Şok hastalarında mortalite belirleyicisi olarak EtCO2 kullanılabilir ve EtCO2 ölçümünün non-invaziv olarak hızlı ve kolay elde edilebilir olması; erken tanı konup hızla resüsitatif tedavinin başlanması gereken şok hastaları için önemli bir yer tutacaktır. EtCO2 değerlerinin laktat ile korele olması EtCO2'i klinik açıdan daha anlamlı hale getirmektedir. Ayrıca kontrol 2.saat EtCO2 ölçümlerinin mortalite belirlemede ilk ölçümlere göre daha duyarlı saptanması; hastalarda kapnograf ile EtCO2 monitörizasyonunun yapılması mortalite öngörüsü açısından daha iyi klinik sonuçlar verebilir.
OBJECTIVES: End-tidal CO2 is a new, non-invasive parameter that is easy and quick to measure. The objective of this study was to determine the clinical value of EtCO2 and its relations with monitor parameters and laboratory values, in evaluating patients with shock and predicting their mortalities; in patients treated for shock in the emergency department. METHODS: Prospective cross-sectional study was designed to include patients diagnosed as shock in Ege University Department of Emergency Medicine. Systolic and diastolic blood pressures, pulse rate, respiratory rate, body temperature, oxygen saturation and EtCO2 levels were recorded. EtCO2 levels were recorded by macrostream method in intubated patients and by sidestream method in patients with spontaneous respiration. Blood gas and laboratory values were recorded and on 2nd hour control vital signs, EtCO2 and lactate levels were measured. SOFA scores were calculated and recorded for each patient. First day mortality, internation or externation status were recorded. Following hospital internalization or externation, patients were tracked to measure 30 day mortality. RESULTS: 300 patients were included in the study. Mean age was 68±16. 46.3% were male and 53.7% were female. Mean EtCO2 value was 21.4±6.4 mmHg. Mortality in the first 24 hours was 16.7%, mortality in the first 30 days was 56.7%. In the patient group who died in the first 24 hours, mean EtCO2 was 17.2 (95% CI:18.4-20.5), while in the patient group who survived, mean EtCO2 was 22.3 (95% CI:23.4-25.2). The difference between these two groups, were considered to be statistically significant (p<0.001). When monitor parameters were compared with ROC analysis by means of predicting 1st day mortality, area under the curve was largest for EtCO2 (AUC:0.76; %95 GA:0.66-0.84; p<0.001). Area under the curve for 2nd hour control EtCO2 measurements was even larger (AUC:0.81; %95 CI:0.73-0.90; p<0.001). In the group of patients who died within 30 days, EtCO2 levels were statistically significant (p<0.001) and area under the curve in the ROC curve analysis was similar to that of 1st day mortality. Cut-off value for EtCO2 was determined as 21mmHg, using the ROC analysis and 50% percentile. For patients with EtCO2 levels≤ 21mmHg, sensitivity was 78%, specificity was 52.8% and negative predictive value was 92.3%. The relative risk of low EtCO2 levels in determining 1st day mortality were calculated as 3.42. A negative correlation was found between lactate and EtCO2 levels (p=0,026). EtCO2 was found to be correlated to bicarbonate (p<0,001) and base excess (p<0,001) but not correlated to pH (p=0,349). CONCLUSION: EtCO2 may be used to predict mortality in patients with shock. The fact that EtCO2 measurement is fast and non-invasive is crucial for shock patients who require early diagnosis and immediate treatment. The correlation of EtCO2 levels with lactate renders EtCO2 even more significant. Monitoring EtCO2 in patients with capnography may reveal better clinical results by means of predicting mortality.
OBJECTIVES: End-tidal CO2 is a new, non-invasive parameter that is easy and quick to measure. The objective of this study was to determine the clinical value of EtCO2 and its relations with monitor parameters and laboratory values, in evaluating patients with shock and predicting their mortalities; in patients treated for shock in the emergency department. METHODS: Prospective cross-sectional study was designed to include patients diagnosed as shock in Ege University Department of Emergency Medicine. Systolic and diastolic blood pressures, pulse rate, respiratory rate, body temperature, oxygen saturation and EtCO2 levels were recorded. EtCO2 levels were recorded by macrostream method in intubated patients and by sidestream method in patients with spontaneous respiration. Blood gas and laboratory values were recorded and on 2nd hour control vital signs, EtCO2 and lactate levels were measured. SOFA scores were calculated and recorded for each patient. First day mortality, internation or externation status were recorded. Following hospital internalization or externation, patients were tracked to measure 30 day mortality. RESULTS: 300 patients were included in the study. Mean age was 68±16. 46.3% were male and 53.7% were female. Mean EtCO2 value was 21.4±6.4 mmHg. Mortality in the first 24 hours was 16.7%, mortality in the first 30 days was 56.7%. In the patient group who died in the first 24 hours, mean EtCO2 was 17.2 (95% CI:18.4-20.5), while in the patient group who survived, mean EtCO2 was 22.3 (95% CI:23.4-25.2). The difference between these two groups, were considered to be statistically significant (p<0.001). When monitor parameters were compared with ROC analysis by means of predicting 1st day mortality, area under the curve was largest for EtCO2 (AUC:0.76; %95 GA:0.66-0.84; p<0.001). Area under the curve for 2nd hour control EtCO2 measurements was even larger (AUC:0.81; %95 CI:0.73-0.90; p<0.001). In the group of patients who died within 30 days, EtCO2 levels were statistically significant (p<0.001) and area under the curve in the ROC curve analysis was similar to that of 1st day mortality. Cut-off value for EtCO2 was determined as 21mmHg, using the ROC analysis and 50% percentile. For patients with EtCO2 levels≤ 21mmHg, sensitivity was 78%, specificity was 52.8% and negative predictive value was 92.3%. The relative risk of low EtCO2 levels in determining 1st day mortality were calculated as 3.42. A negative correlation was found between lactate and EtCO2 levels (p=0,026). EtCO2 was found to be correlated to bicarbonate (p<0,001) and base excess (p<0,001) but not correlated to pH (p=0,349). CONCLUSION: EtCO2 may be used to predict mortality in patients with shock. The fact that EtCO2 measurement is fast and non-invasive is crucial for shock patients who require early diagnosis and immediate treatment. The correlation of EtCO2 levels with lactate renders EtCO2 even more significant. Monitoring EtCO2 in patients with capnography may reveal better clinical results by means of predicting mortality.
Açıklama
Anahtar Kelimeler
Şok, End-Tidal Karbondioksit, Mortalite, Laktat, SOFA Skoru, Shock, End-tidal Carbondioxide, Mortality, Lactate, SOFA Score
