Sympathetic stimulation increases serum lactate concentrations in patients admitted with sepsis: implications for resuscitation strategies

Abstract Background Diametrically opposed positions exist regarding the deleterious effects of elevated lactate. There are data suggesting that it is a detrimental proxy for tissue hypoperfusion and anaerobic metabolism in sepsis and an alternative viewpoint is that some of the hyperlactatemia produced maybe adaptive. This study was conducted to explore the relationship between serum lactate levels, mean arterial blood pressure (MAP), and sympathetic stimulation in patients with sepsis. Methods Retrospective analysis of prospectively collected clinical data from four community-based hospitals and one academic medical center. 8173 adults were included. Heart rate (HR) was used as a surrogate marker of sympathetic stimulation. HR, MAP, and lactate levels were measured upon presentation. Results MAP and HR interacted to affect lactate levels with the highest levels observed in patients with low MAP and high HR (3.6 mmol/L) and the lowest in patients with high MAP and low HR (2.2 mmol/L). The overall mortality rate was 12.4%. Each 10 beats/min increase in HR increased the odds of death 6.0% (95% CI 2.6% to 9.4%), each 1 mmol/L increase in lactate increased the odds of death 20.8% (95% CI 17.4% to 24.2%), whereas each 10 mmHg increase in MAP reduced the odds of death 12.3% (95% CI 9.2% to 15.4%). However, HR did not moderate or mediate the association between lactate and death. Conclusions In septic patients, lactate production was associated with increased sympathetic activity (HR ≥ 90) and hypotension (MAP < 65 mmHg) and was a significant predictor of mortality. Because HR, lactate, and MAP were associated with mortality, our data support the present strategy of using these measurements to gauge severity of illness upon presentation. Since HR did not moderate or mediate the association between lactate and death, criticisms alleging that lactate caused by sympathetic stimulation is adaptive (i.e., less harmful) do not appear substantiated.

Download Full-text

ICU Admission Source as a Predictor of Mortality for Patients With Sepsis

Journal of Intensive Care Medicine ◽

10.1177/0885066617701904 ◽

2017 ◽

Vol 33 (9) ◽

pp. 510-516 ◽

Cited By ~ 5

Author(s):

Christine A. Motzkus ◽

Stavroula A. Chrysanthopoulou ◽

Roger Luckmann ◽

Teresa A. Rincon ◽

Kate L. Lapane ◽

...

Keyword(s):

Medical Center ◽

Academic Medical Center ◽

Severity Of Illness ◽

Hospital Ward ◽

Icu Admission ◽

Admission Source ◽

Academic Medical ◽

Record Data ◽

Hospital Wards ◽

Selection Of

Purpose: Sepsis is the leading noncardiac cause of intensive care unit (ICU) death. Pre-ICU admission site may be associated with mortality of ICU patients with sepsis. This study quantifies mortality differences among patients with sepsis admitted to an ICU from a hospital ward, emergency department (ED), or an operating room (OR). Methods: We conducted a retrospective cohort study of 1762 adults with sepsis using ICU record data obtained from a clinical database of an academic medical center. Survival analysis provided crude and adjusted hazard rate ratio (HRR) estimates comparing hospital mortality among patients from hospital wards, EDs, and ORs, adjusted for age, sex, and severity of illness. Results: Mortality of patients with sepsis differed based on the pre-ICU admission site. Compared to patients admitted from an ED, patients admitted from hospital wards had higher mortality (HRR: 1.35; 95% confidence interval [CI]: 1.09-1.68) and those admitted from an OR had lower mortality (HRR: 0.37; 95% CI: 0.23-0.58). Conclusion: Patients with sepsis admitted to an ICU from a hospital ward experienced greater mortality than patients with sepsis admitted to an ICU from an ED. These findings indicate that there may be systematic differences in the selection of patient care locations, recognition, and management of patients with sepsis that warrant further investigation.

Download Full-text

A Neutrophil Subset Defined by Intracellular Olfactomedin 4 is Associated with Mortality in Sepsis

AJP Lung Cellular and Molecular Physiology ◽

10.1152/ajplung.00090.2020 ◽

2020 ◽

Author(s):

Kirsten Neudoerffer Kangelaris ◽

Regina Clemens ◽

Xiaohui Fang ◽

Alejandra Jauregui ◽

Tom Liu ◽

...

Keyword(s):

Host Response ◽

Medical Center ◽

Academic Medical Center ◽

Severity Of Illness ◽

Youden Index ◽

Prognostic Information ◽

Suspected Sepsis ◽

Neutrophil Percentage ◽

Academic Medical ◽

Poor Outcomes

Sepsis is a heterogeneous syndrome clinically and biologically but biomarkers of distinct host response pathways for early prognostic information and testing targeted treatments are lacking. We hypothesized that Olfactomedin 4 (OLFM4), a matrix glycoprotein of neutrophil specific granules defines a distinct neutrophil subset that may be an independent risk factor for poor outcomes in sepsis. In a single-center, prospective cohort study, we enrolled adults admitted to an academic medical center from the Emergency Department (ED) with suspected sepsis (identified by 2 or greater Systemic Inflammatory Response Syndrome [SIRS] criteria and antibiotic receipt) from March 2016 through December 2017, followed by sepsis adjudication according to Sepsis-3. We collected 200mL of whole blood within 24 hours of admission and stained for the neutrophil surface marker CD66b followed by intracellular staining for OLFM4 quantitated by flow cytometry. The predictor for 60-day mortality was the percentage of OLFM4+ neutrophils and at a cut-point of OLFM4+ ≥37.6% determined by the Youden Index. Of 120 enrolled patients with suspected sepsis, 97 had sepsis and 23 had non-sepsis SIRS. The mean percentage of OLFM4+ neutrophils was significantly increased in both sepsis and non-sepsis SIRS patients who died (P ≤ 0.01). Among sepsis patients with elevated OLFM4+(≥37.6%), 56% died compared to 18% with OLFM4+ <37.6% (P=0.001).The association between OLFM4+ and mortality withstood adjustment for demographics, co-morbidities and measures of severity of illness (P<0.03). In sepsis, OLFM4+ neutrophil percentage is independently associated with 60-day mortality and may represent a novel measure of the heterogeneity of host response to sepsis.

Download Full-text

Survival in critically ill admissions with and without COVID-19 at an academic medical center during the height of the pandemic

Journal of Hospital Administration ◽

10.5430/jha.v10n2p29 ◽

2021 ◽

Vol 10 (2) ◽

pp. 29

Author(s):

Caroline A. Ricard ◽

Janelle O'keeffe Poyant ◽

Sharon L. Holewinski ◽

Stanley A. Nasraway Jr

Keyword(s):

Intensive Care ◽

Hospital Mortality ◽

Critically Ill ◽

Medical Center ◽

Academic Medical Center ◽

Severity Of Illness ◽

Mortality Rates ◽

Academic Medical ◽

Crude Mortality ◽

Significant Difference

Objective: Early reports demonstrate that patients with Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection have high rates of hospitalization, intensive care unit (ICU) admission, and death. We sought to examine characteristics of ICU admissions with and without Coronavirus 2019 (COVID-19) and to compare outcomes between these two critically ill cohorts.Methods: A retrospective analysis of 600 unique adult ICU admissions was conducted at an academic medical center in Boston, MA from March 22 to May 31, 2020.Results: Of 600 ICU admissions, 170 (28.3%) tested positive for COVID-19. Those with COVID-19 had greater severity of illness and were more likely to require mechanical ventilation (MV). Hospital and ICU mortality rates were greater in the COVID-19 group (22.4% vs. 9.5%; 18.2% vs. 7.2%, respectively), but lower than previous reports. Unadjusted odds ratio (OR) for COVID-19 as a predictor of hospital mortality was 2.73 (95% CI 1.68 to 4.43), but when accounting for clinical characteristics and severity of illness, adjusted OR for hospital mortality was no different (1.09 [95% CI 0.50 to 2.41]) among those with and without COVID-19.Conclusions: COVID-19 admissions had greater severity of illness and suffered higher crude mortality rates compared to the non-COVID-19 cohort. However, there was no significant difference in the adjusted OR for hospital mortality between patients with and without COVID-19. This novel finding may be attributed to the “learning curve” from other healthcare system experiences, early hospital-wide preparation, and dedicated intensive care.

Download Full-text