Lactate clearance for death prediction in severe sepsis or septic shock patients during the first 24 hours in Intensive Care Unit: an observational study

BackgroundThis study was design to investigate the prognostic value for death at day-28 of lactate course and lactate clearance during the first 24 hours in Intensive Care Unit (ICU), after initial resuscitation.MethodsProspective, observational study in one surgical ICU in a university hospital. Ninety-four patients hospitalized in the ICU for severe sepsis or septic shock were included. In this septic cohort, we measured blood lactate concentration at ICU admission (H0) and at H6, H12, and H24. Lactate clearance was calculated as followed: [(lactateinitial - lactatedelayed)/ lactateinitial] x 100%].ResultsThe mean time between severe sepsis diagnosis and H0 (ICU admission) was 8.0 ± 4.5 hours. Forty-two (45%) patients died at day 28. Lactate clearance was higher in survivors than in nonsurvivors patients for H0-H6 period (13 ± 38% and −13 ± 7% respectively, p = 0.021) and for the H0-H24 period (42 ± 33% and −17 ± 76% respectively, p < 0.001). The best predictor of death at day 28 was lactate clearance for the H0-H24 period (AUC = 0.791; 95% CI 0.6-0.85). Logistic regression found that H0-H24 lactate clearance was independently correlated to a survival status with a p = 0.047 [odds ratio = 0.35 (95% CI 0.01-0.76)].ConclusionsDuring the first 24 hr in the ICU, lactate clearance was the best parameter associated with 28-day mortality rate in septic patients. Protocol of lactate clearance-directed therapy should be considered in septic patients, even after the golden hours.

[1]  E. Ivers,et al.  Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock , 2001 .

[2]  P. Nabet,et al.  Evolution of lactate/pyruvate and arterial ketone body ratios in the early course of catecholamine‐treated septic shock , 2000, Critical care medicine.

[3]  Stein Silva,et al.  Central venous-to-arterial carbon dioxide difference: an additional target for goal-directed therapy in septic shock? , 2008, Intensive Care Medicine.

[4]  C. Sprung,et al.  Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock 2012 , 2013, Critical care medicine.

[5]  Huan-huan Tian,et al.  [The effect of early goal lactate clearance rate on the outcome of septic shock patients with severe pneumonia]. , 2012, Zhongguo wei zhong bing ji jiu yi xue = Chinese critical care medicine = Zhongguo weizhongbing jijiuyixue.

[6]  D. Annane,et al.  Corticosteroid treatment and intensive insulin therapy for septic shock in adults: a randomized controlled trial. , 2010, JAMA.

[7]  P. Jambou,et al.  Mild hyperlactatemia in stable septic patients is due to impaired lactate clearance rather than overproduction. , 1998, American journal of respiratory and critical care medicine.

[8]  G. Jacobsen,et al.  Early lactate clearance is associated with improved outcome in severe sepsis and septic shock* , 2004, Critical care medicine.

[9]  E. Rivers,et al.  Early goal-directed therapy in severe sepsis and septic shock: converting science to reality. , 2006, Chest.

[10]  V. Pettilä,et al.  Hemodynamic variables related to outcome in septic shock , 2005, Intensive Care Medicine.

[11]  R. Cowley,et al.  Blood Lactate in the Prognosis of Various Forms of Shock , 1971, Annals of surgery.

[12]  W. Kuan,et al.  Outcome effectiveness of the severe sepsis resuscitation bundle with addition of lactate clearance as a bundle item: a multi-national evaluation , 2011, Critical care.

[13]  J. Gogas,et al.  Central Venous and Mixed Venous Oxygen Saturation in Critically Ill Patients , 2001, Respiration.

[14]  C. Pradier,et al.  Blood pressure and arterial lactate level are early indicators of short-term survival in human septic shock , 2005, Intensive Care Medicine.

[15]  J. Vincent,et al.  Blood lactate levels are better prognostic indicators than TNF and IL-6 levels in patients with septic shock , 1996, Intensive Care Medicine.

[16]  M. Levy,et al.  Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008 , 2007, Intensive Care Medicine.

[17]  M. Fink.  Cytopathic hypoxia. Is oxygen use impaired in sepsis as a result of an acquired intrinsic derangement in cellular respiration? , 2002, Critical care clinics.

[18]  J. Fischer,et al.  Lactate is an unreliable indicator of tissue hypoxia in injury or sepsis , 1999, The Lancet.

[19]  M. Cat,et al.  [Blood lactate concentration as prognostic marker in critically ill children]. , 2005, Jornal de pediatria.

[20]  Claude D Martin,et al.  High central venous oxygen saturation in the latter stages of septic shock is associated with increased mortality , 2011, Critical care.

[21]  J. Vincent,et al.  Serial blood lactate levels can predict the development of multiple organ failure following septic shock. , 1996, American journal of surgery.

[22]  J. Bakker,et al.  Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial. , 2010, American journal of respiratory and critical care medicine.

[23]  C. Ince,et al.  Microcirculatory oxygenation and shunting in sepsis and shock. , 1999, Critical care medicine.

[24]  J. Vincent,et al.  Combined measurements of blood lactate concentrations and gastric intramucosal pH in patients with severe sepsis. , 1995, Critical care medicine.

[25]  Richard Beale,et al.  The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis , 2010, Intensive Care Medicine.

[26]  G. Friedman,et al.  Occult hypoperfusion is associated with increased mortality in hemodynamically stable, high-risk, surgical patients , 2004, Critical care.

[27]  M. Donnino,et al.  Effective lactate clearance is associated with improved outcome in post-cardiac arrest patients. , 2007, Resuscitation.

[28]  O. Fourcade,et al.  The hemodynamic "target": a visual tool of goal-directed therapy for septic patients. , 2007, Clinics.

[29]  Alan E. Jones,et al.  Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. , 2010, JAMA.

[30]  J. Siegel,et al.  Bench-to-bedside review: Oxygen debt and its metabolic correlates as quantifiers of the severity of hemorrhagic and post-traumatic shock , 2005, Critical care.

[31]  Jeffrey A. Kline,et al.  The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: A meta-analysis* , 2008, Critical care medicine.

[32]  J. Saffle,et al.  The Relationship of Serum Lactate and Base Deficit in Burn Patients to Mortality , 2007, Journal of burn care & research : official publication of the American Burn Association.

[33]  Jay Steingrub,et al.  International study of the prevalence and outcomes of infection in intensive care units , 2009 .

[34]  Central venous oxygen saturation in septic shock - a marker of cardiac output, microvascular shunting and/or dysoxia? , 2011, Critical care.