scholarly journals Role of Arterial Serum Lactate as a Predictor of Undifferentiated Shock on Admission and its Outcome- A Cohort Study

Author(s):  
Avadhesh Kumar Sharma ◽  
Nandakumar Beke ◽  
Dattatray Patki ◽  
Arun Bahulikar ◽  
Deepak Sadashiv Phalgune

Introduction: Patients with elevated serum lactate levels may be at risk for considerable morbidity and mortality and require a prompt, thoughtful and systematic approach for diagnosis and treatment. Aim: To find an association of on admission arterial serum lactate with outcome in Intensive Care Unit (ICU) patients. Materials and Methods: This observational cohort study was conducted on 168 patients at Poona Hospital and Research Centre, Pune, India, between June 2018 to November 2019 after obtaining Institutional Ethical Clearance. The patients included were above 18 years of age who had Systolic Blood Pressure (SBP) <90 mmHg, Heart Rate (HR) >100/min and Respiratory Rate (RR) >20/min. The arterial serum lactate level were examined on the day of admission, 12 hours and 24 hours. The need of ionotropic support, duration of ICU stay and mortality in one month was noted. The primary outcome measures were to study the association of on admission arterial serum lactate level with a duration of ICU stay and in-hospital mortality, whereas the secondary outcome measure was to study the association of on admission arterial serum lactate with the requirement of ionotropic support. Analysis of data was done using Statistical Package for Social Sciences for Windows, version 20.0. Results: The incidence in-hospital mortality was 20 (22.7%) out of 88 and 3 (3.8%) out of 80 in patients whose serum lactate levels on admission were >36 mg/dL and ≤36 mg/dL, respectively (p-value=0.002). The median duration of ICU stay was six and three days in patients whose serum lactate levels on admission were >36 mg/dL and ≤36 mg/dL, respectively (p-value=0.001). A 87 (98.9%) patients whose serum lactate levels >36 mg/dL on admission had the higher requirement of inotropes as compared to 35 (50.7%) patients whose serum lactate levels were ≤36 mg/dL. The percentage of patients whose serum lactate level >36 mg/dL, had a significantly higher Quick Sequential Organ Failure Assessment (qSOFA) scores and higher Shock Index (SI). There was a statistically significant positive correlation between serum lactate levels and qSOFA score (r=0.555) and SI (r=0.559). Conclusion: Initial serum lactate level was associated with higher in-hospital mortality, the higher requirement of inotropic support and longer duration of ICU stay.

Author(s):  
Ralphe Bou Chebl ◽  
Sarah Jamali ◽  
Nancy Mikati ◽  
Reem Al Assaad ◽  
Karim Abdel Daem ◽  
...  

Abstract Objective The clinical interpretation of lactate ≤ 2.00 mmol/L in emergency department (ED) patients is not well characterized. This study aims to determine the optimal cutoff value for lactate within the reference range that predicts in-hospital mortality among ED patients with initial serum lactate levels within the reference range. Methods This was a retrospective study of adult patients presenting to a tertiary ED between the dates of January 1, 2014 and June 30, 2019 with an initial serum lactate level less than 2.00 mmol/L. The primary outcome was in-hospital mortality. Youden’s index was utilized to determine the optimal threshold that predicts mortality. Patients above the threshold were labeled as having relative hyperlactatemia. A multivariate logistic regression was performed to determine the association between relative hyperlactatemia and in-hospital mortality. Subgroup analyses were done to further examine the interaction between relative hyperlactatemia and hospital mortality. Results During the study period, 1638 patients were included. The mean age was 66.9 ± 18.6 years, 47.1% of the population were female, and the most prevalent comorbidity was hypertension (56.7%). The mean lactate level at presentation was 1.5 ± 0.3 mmol/L. In-hospital mortality was 3.8% in the overall population and 16.2% were admitted to the ICU. A lactate of 1.33 mmol/L was found to be the optimal cutoff that best discriminates between survivors and non-survivors. Relative hyperlactatemia was an independent predictor of in-hospital mortality (OR 1.78 CI1.18-4.03; p 0.02). Finally, Relative hyperlactatemia was associated with increased mortality in patients without hypertension (4.7% versus 1.1%; p 0.008), as well as patients without diabetes or COPD. Conclusion The optimal cutoff of initial serum lactate that discriminates between survivors and non-survivors is in the ED 1.33 mmol/L. Relative hyperlactatemia is associated with increased mortality in emergency department patients, and this interaction seems to be more important in healthy patients.


Author(s):  
Surbhi Agrawal ◽  
Maria Smith ◽  
Robert Berg ◽  
Iffath A. Hoskins

Objective Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality. At present, there are no reliable clinical or laboratory indicators to identify which patients might require blood transfusions during a PPH. Serum lactate has long been used as an early biomarker of tissue hypoperfusion in trauma settings. The aim of this study is to understand serum lactate's role in the management of obstetric hemorrhage. Study Design A retrospective chart review was performed of women who delivered between 2016 and 2019 at our institution and experienced a PPH. The patients were divided into two groups: those with a normal serum lactate level, defined as ≤2 mmol/L, and those with an abnormal serum lactate level, defined as >2 mmol/L. Need for packed red blood cell transfusion, as part of the resuscitation, was assessed for both groups. Results During the study period, 938 women experienced PPH. Of these, 108 (11.5%) had a normal serum lactate, ≤2 mmol/L, and 830 (88.5%) had an abnormal lactate, >2 mmol/L. Women with elevated lactate levels were more likely to receive a blood transfusion versus those with a normal lactate level (57.0 vs. 46.3%, p = 0.035, respectively). Additionally, the average number of blood transfusions administered was significantly higher in the abnormal lactate group versus in the normal lactate group (1.34 vs. 0.97, respectively, p = 0.004). In a multivariable linear regression model, increasing serum lactate levels were found to be predictive of requiring more than 1 unit of blood (p < 0.001). Conclusion Women with elevated serum lactate levels were more likely to require blood transfusions during a PPH versus those with a normal serum lactate level. Thus, serum lactate levels are useful as an early indicator of requirement for blood transfusion in the management of obstetric hemorrhage. Key Points


2013 ◽  
Vol 2 (1) ◽  
pp. 7-13 ◽  
Author(s):  
P Lamichhane ◽  
S Shrestha ◽  
B Banskota ◽  
AK Banskota

Background: The search for the best marker or set of markers for the diagnosis, prognosis and treatment of ‘at risk’ trauma patients is ongoing. Serial estimation of serum lactate values are thought to help predict morbidity and mortality in trauma victims. There is evidence to support the use of blood lactate levels as an end point of resuscitation. The presence of elevated lactic acid levels in the serum can direct the treating physician to safe and correct timing of any surgical intervention. Early identification and aggressive resuscitation measures aimed at correcting the impaired metabolic dysfunction improves survival and reduces complications in severely injured trauma patients. Methods: A prospective analytical study of 52 patients with polytrauma and multiple trauma admitted within 12 hours of injury to our institution between March 2007 to February 2008 was carried out. All the patients were resuscitated as per the advance trauma life support (ATLS) protocol in the emergency room. Serum lactate level was analyzed on the 1st, 5th and 14th day of injury. Serum lactate levels greater than 2 milimoles/L was considered abnormal and serum lactate level greater than 5 milimoles/L was considered significant. Results: There were 45 males and 7 females with an average age of 32.8 years (18-82). 18 patients out of 52 sustained polytrauma. Of these 18 patients, 8 patients sustained chest injury, 4 had head injury and 2 had abdominal injury. In the polytrauma group (n-18), 5 patients had an elevated lactate above 2 milimoles/Lon admission. 2 patients who had significant rise of lactate (>5 milimoles/L) on admission died on the 5th day. Out of 34 multiple trauma patients, 13 patients had an elevated lactate level at admission. One patient in this group with lactate level 7.2 died of ARDS on 3rd day of admission. Conclusion: Blood lactate appears to be a reliable marker reflecting not only the severity of the shock, but also for predicting survival. The longer the lactate is elevated, the more a patient is likely to develop multiple organ dysfunctions and die. Lactate levels followed over time is more reliable than isolated values. DOI: http://dx.doi.org/10.3126/noaj.v2i1.8134 Nepal Orthopaedic Association Journal Vol.2(1) 2011: 7-13


2019 ◽  
Vol 160 (45) ◽  
pp. 1784-1790
Author(s):  
Kinga Jenei ◽  
Ildikó Szatmári ◽  
Eszter Szabó ◽  
Anjum Mariam ◽  
Andrea Luczay ◽  
...  

Abstract: Introduction: It is known that lactate concentration is increased in diabetic ketoacidosis (DKA), however, the pathophysiology and kinetics of lactate changes are still unclear. Normally, L-lactate is the major form in the human body. According to previous data, also D- and L-lactate might be increased in hyperglycaemic disorders. Aim: We aimed to describe the kinetics and mechanisms of lactate concentration changes in ketoacidosis and newly diagnosed diabetes. Method: We performed a prospective study, including 5–18-year-old children with ketoacidosis (DKA, n = 13) and with newly diagnosed type 1 diabetes without ketoacidosis (T1DM, n = 6). We performed routine blood gas analysis 0–12–24–48 hours after admission, which also measured L-lactate levels. We also determined total venous serum lactate level by gas chromatography–mass spectrometry. Results: Initial plasma lactate concentration was increased in ketoacidosis as compared to the newly diagnosed diabetes group (p<0.05). After 12 h of rehydration, lactate levels were greatly reduced in ketoacidotic patients but after 24–48 h it was repeatedly increased (all p<0.01). In the 0–12 h phase, total serum lactate level was higher than L-lactate level, referring to D-lactate production. Conclusion: We described two L-lactate peaks in ketoacidosis. In the first 12 hours anaerobic glycolysis seems to have major role in hyperlactataemia. We assume that stimulated aerobic glycolysis leads to the second lactate peak. However, D-lactate is not routinely measured, it may contribute to the initial hyperlactataemia in both groups and is comparable to L-lactate production in ketoacidosis. Orv Hetil. 2019; 160(45): 1784–1790.


2019 ◽  
Vol 2019 ◽  
pp. 1-7 ◽  
Author(s):  
Cheol Lee ◽  
Juhwan Lee ◽  
Hyunho Cho ◽  
Jaekyeong Song ◽  
Hojung Jung ◽  
...  

Background. Several studies have shown the utility of lactate level as a predictor of early outcomes in trauma patients. We conducted this study to evaluate the association of perioperative serum lactate levels with postoperative delirium (POD) in elderly trauma patients. Materials and Methods. This study included 466 elderly trauma patients with measurements of serum lactate levels on admission and 1 h after surgery. The associations of POD with serum lactate levels (on admission and 1 h after surgery) and lactate clearance were analyzed using Kendall’s correlation. Perioperative serum lactate levels and lactate clearance as predictors of POD were evaluated using univariate and multivariable analyses. Results. The incidence of POD in the present study was 38.1%. Serum lactate levels on admission and at 1 h after surgery were significantly higher in major trauma than in minor trauma. In univariate analysis of perioperative serum lactate levels and lactate clearance as predictors of POD, the odds ratio (OR) for serum lactate level on admission was 4.19 (P<0.01, 2.91 < 95% confidence interval (CI) < 6.02) and that 1 h after surgery was 3.83 (P<0.01, 2.79 < 95% CI < 5.25); however, the OR for serum change of lactate level was 0.99 ((P<0.09, 0.99 < 95% CI < 1.00). In multivariable analysis for predictors of POD, the OR for serum lactate level on admission was 2.40 (P<0.09, 0.87 < 95% CI < 6.7), that for serum lactate 1 h after surgery was 2.83 (P=0.01, 1.28 < 95% CI < 6.24), that for ICU admission was 3.01 (P=0.01, 2.09 < 95% CI < 6.03), and that for ISS was 1.47 (P<0.01, 1.27 < 95% CI < 3.70). Conclusions. Taking together the results of univariate and multivariable analyses, serum lactate level 1 h after surgery may be used as a prediction model of POD development in elderly trauma patients.


2019 ◽  
Vol 2 (1) ◽  
pp. 43-51
Author(s):  
Rupak Bhandari ◽  
R Bhandari ◽  
M Paudel ◽  
G B Malla

Background: Sepsis and Septic shock are a common presentation in the Emergency Department with high morbidity and mortality. Serum lactate level increases substantially in the patients with septic shock. The objectives of this study were to determine serum lactate levels at the time of presentation, find out the outcome and correlate lactate levels with the outcome in the patients with septic shock. Methods: It is a prospective cross-sectional study of patients presenting to the Emergency, who met the criteria for septic shock defined by Surviving Sepsis Guidelines 2012. Patients’ demographics, co morbidity, triage vitals, laboratory and radiological parameters were recorded. The primary outcome was mortality and secondary outcomes were duration of stay in hospital and complications, if any, developed during hospital stay. Results: Eighty-four cases were enrolled, with male to female ratio of 1:1. Mean age was46.40 19.59 years. The significant variables were: serum lactate (p<0.001), pH level (p= 0.001), serum creatinine (p= 0.002) and INR level (p= 0.001). Serum lactate was the significant factor that correlated with mortality after applying multivariate regression analysis (OR= 2.75, CI= 0.890- 4.041,p= 0.001). Conclusion: Initial serum lactate level is independently associated with mortality of the patients presenting to ED with septic shock.


Circulation ◽  
2019 ◽  
Vol 140 (Suppl_2) ◽  
Author(s):  
Norihiro Nishioka ◽  
Daisuke Kobayashi ◽  
Junichi Izawa ◽  
Takeyuki Kiguchi ◽  
Tetsuhisa Kitamura ◽  
...  

Background: Serum lactate reflects hypoxic insult in many conditions, but its role as prognostic markers after cardiac arrest is still controversial. This study aimed to investigate the association between serum lactate levels during cardiopulmonary resuscitation (CPR) and survival in patients with out-of-hospital cardiac arrest (OHCA). Methods: This study analyzed the data of the Osaka Comprehensive Registry of Intensive Care for OHCA Survival, a prospective multicenter observational study of 14 participating institutions in Osaka Prefecture, Japan. We enrolled consecutive patients aged ≥18 years who were transported to the hospital with ongoing CPR from 2013 to 2016. Based on the serum lactate levels, OHCA patients were divided into 4 quartiles: Q1 (lactate ≤10.6 mEq/L), Q2 (10.6< lactate ≤14.1 mEq/L), Q3 (14.1< lactate ≤18.0 mEq/L) and Q4 (lactate >18.0 mEq/L). The relationships between serum lactate level before return of spontaneous circulation (ROSC) and 1-month survival were assessed. Results: A total of 3,674 OHCA patients were included in the analysis. Overall 1-month survival was 2.3% (88/3,674). The Q1 group had the highest 1-month survival (4.6% [42/921]), followed by Q2 (2.7% [25/920]), Q3 (1.1% [11/966]) and Q4 (0.6% [5/867]), respectively (p for trend < 0.001). In the multivariable logistic regression analysis, the proportion of 1-month survival in the Q4 group was significantly lower, compared with that in the Q1 group (adjusted odds ratio 0.23; 95% confidence interval 0.09 to 0.60). The adjusted proportion of 1-month survival decreased in a stepwise manner across increasing quartiles (p for trend <0.001). In a subgroup analysis by initial rhythm, there was a significant interaction (p=0.003) between the rhythms: 1-month survival of OHCA patients presented with a non-shockable rhythm decreased when the lactate levels increased (p for trend < 0.001), but in patients with a shockable rhythm the similar trend was not observed (p for trend = 0.574). Conclusions: The high serum lactate level before ROSC significantly associated with the worse 1-month survival after OHCA. Serum lactate may be one of the effective prognostic indications for OHCA during CPR, especially with non-shockable initial rhythm.


2020 ◽  
Author(s):  
Norihiro Nishioka ◽  
Daisuke Kobayashi ◽  
Junichi Izawa ◽  
Taro Irisawa ◽  
Tomoki Yamada ◽  
...  

Abstract Background: Serum lactate reflects hypoxic insult in many conditions, but its role as prognostic markers after cardiac arrest is still controversial. This study aimed to investigate the association between serum lactate levels during cardiopulmonary resuscitation (CPR) and survival in patients with out-of-hospital cardiac arrest (OHCA).Methods:We analyzed the data of the Osaka Comprehensive Registry of Intensive Care for OHCA Survival (CRITICAL) study, a prospective multicenter observational study of 14 participating institutions in Osaka Prefecture, Japan that enrolled consecutive OHCA patients. We included adult nontraumatic OHCA patients transported to the hospital with ongoing CPR from 2013 to 2017. Based on the serum lactate levels during CPR, the patients were divided into four quartiles: Q1 (lactate ≤ 10.6 mEq/L), Q2 (10.6 < lactate ≤ 14.1 mEq/L), Q3 (14.1 < lactate ≤ 18.0 mEq/L), and Q4 (lactate > 18.0 mEq/L). The primary outcome of this study was 1-month survival. Results:A total of 11,960 patients were registered and 4,978 of them were eligible for our analyses. The Q1 group had the highest 1-month survival (4.3% [53/1,245]), followed by Q2 (2.5% [31/1,245]), Q3 (1.1% [14/1,328]), and Q4 (0.5% [6/1,160]) groups. In the multivariable logistic regression analysis, the proportion of 1-month survival in the Q4 group was significantly lower than that in the Q1 group (adjusted odds ratio 0.21; 95% confidence interval 0.086 to 0.50). One-month survival decreased in a stepwise manner as the quartiles increased (p for trend <0.001). In subgroup analysis, there was a significant interaction between initial rhythm and survival (p for interaction <0.001); 1-month survival of patients with a non-shockable rhythm decreased when the lactate levels increased (p for trend <0.001), but not in patients with a shockable rhythm (p for trend =0.76).CONCLUSION:High serum lactate level during CPR was associated with poor 1-month survival in OHCA patients. Serum lactate may be one of the effective prognostic indications for OHCA during CPR, especially in patients with non-shockable rhythm.


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