Abstract
BackgroundBased on the proven efficacy of lactate in predicting mortality and morbidity in sepsis when measured early in the resuscitative protocol, our group hypothesized that this utility extends later in the course of care. This study sought to investigate the prognostic potential of plasma lactate clearance measured 24–48 h after the initiation of treatment for nonsurgical patients with sepsis, severe sepsis, and septic shock.MethodsPlasma lactate values, measured 24–48 h after the initiation of treatment, were collected in nonsurgical septic, severe septic, and septic shock patients. The primary outcome was 30-day mortality, while secondary outcomes included requirements for vasopressors and boluses of intravenous fluids. Analysis of these three outcomes was performed while controlling for clinical severity as measured by Sequential Organ Failure Assessment (SOFA), renal dysfunction, and hepatic dysfunction. Lactate clearance was defined as the percent change in plasma lactate levels measured after 24–48 h of treatment from the plasma lactate level at initial presentation.ResultsTwo hundred twenty-nine nonsurgical patients were divided into two groups, clearers (above median lactate clearance [31.6 %]) and nonclearers (below median lactate clearance [31.6 %]). The adjusted odds ratio of mortality in clearers compared to nonclearers was 0.39 (CI 0.20–0.76) (p = 0.006). For vasopressor requirement, the adjusted odds ratio was 0.41 (CI 0.21–0.79) in clearers compared to nonclearers (p = 0.008). For intravenous fluid bolus requirement, the adjusted odds ratio was 0.81 (CI 0.48–1.39) in clearers compared to nonclearers (p = 0.45).ConclusionsLower plasma lactate clearance 24–48 h after the initiation of treatment is associated with higher 30-day mortality and requirements for vasopressors in nonsurgical septic patients and may be a useful noninvasive measurement for guiding late-sepsis treatment. Further investigation looking at mechanisms and therapeutic targets to improve lactate clearance in late sepsis may improve patient mortality and outcomes.
Highlights
Based on the proven efficacy of lactate in predicting mortality and morbidity in sepsis when measured early in the resuscitative protocol, our group hypothesized that this utility extends later in the course of care
Before controlling for Sequential Organ Failure Assessment (SOFA), the odds of mortality in clearers compared to nonclearers was 0.44 with 95 % confidence interval (0.24–0.78)
Multiple logistic regression modeling was performed with lactate clearance, estimated glomerular filtration rate (EGFR), Model for End-Stage Liver Disease (MELD), and SOFA score, with the odds ratio and confidence interval being 0.39 (0.20–0.76) (p = 0.006), respectively (Figs. 3 and 4)
Summary
Based on the proven efficacy of lactate in predicting mortality and morbidity in sepsis when measured early in the resuscitative protocol, our group hypothesized that this utility extends later in the course of care. A decade since the landmark article, “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock”, sepsis remains a hotbed of research, and new diagnostic and resuscitative interventions are continually under development and evaluation. One such effort that has received focus is the role of lactate monitoring [1, 3,4,5]. It was shown that lactate clearance greater than 10 % from initial measurement during the first 2 to 6 h of resuscitation predicted survival from septic shock and that protocols targeting lactate clearance of at least 10 % produced similar shortterm survival rates to protocols using central venous oxygen saturation (ScVO2) monitoring [2, 3, 9, 11]
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