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Abstract

We agree with Drs Bakker and Hernandez that our work does not prove a causal relationship between delayed lactate measurements and increased mortality in patients with initially elevated lactate measurements, but rather an association.1Han X. Edelson D.P. Snyder A.M. et al.Implications of Centers for Medicare & Medicaid Services Severe Sepsis and Septic Shock Early Management Bundle and initial lactate measurement on the management of sepsis.Chest. 2018; 154: 302-308Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar The fact that this association is no longer significant when adjusted for time to antibiotic and intravenous fluid administration suggests that earlier interventions likely mediate this association. Even after adjusting for severity of illness, we found that abnormal lactate values were correlated with more rapid interventions by clinicians. Based on the body of literature demonstrating the mortality benefits of early antibiotic administration, more rapid antibiotic administration likely plays a significant role in our findings.2Seymour C.W. Gesten F. Prescott H.C. et al.Time to treatment and mortality during mandated emergency care for sepsis.N Engl J Med. 2017; 376: 2235-2244Crossref PubMed Scopus (1030) Google Scholar, 3Liu V.X. Fielding-Singh V. Greene J.D. et al.The timing of early antibiotics and hospital mortality in sepsis.Am J Respir Crit Care Med. 2017; 196: 856-863Crossref PubMed Scopus (389) Google Scholar We also agree that there could certainly be other mechanisms, confounders, and interventions contributing to the observed increase in mortality that we did not investigate. We do not suggest that every elevated lactate value should be treated by the administration of fluids and agree that the appropriate clinical response to a septic patient with elevated lactate is complex. As Drs Bakker and Hernandez mention, rapid lactate clearance and normalization of lactate have been studied, with some evidence of mortality benefit. However, much remains unclear regarding the optimal treatment regimen and the generalizability of prior findings.4Jansen T.C. van Bommel J. Schoonderbeek F.J. et al.LACTATE Study GroupEarly lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial.Am J Respir Crit Care Med. 2010; 182: 752-761Crossref PubMed Scopus (619) Google Scholar, 5Jones A.E. Shapiro N.I. Trzeciak S. et al.Emergency Medicine Shock Research Network (EMShockNet) Investigators. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial.JAMA. 2010; 303: 739-746Crossref PubMed Scopus (805) Google Scholar In addition, as seen in our study, a significant proportion of septic patients have normal lactate values. While the appropriate treatment of elevated lactate was outside the scope of our study, it is an area of important continued investigation. Last, the majority of admissions in our study were prior to the implementation of the Centers for Medicare & Medicaid Services Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). We applied the criteria of the bundle retrospectively to all admissions, but since the majority of them preceded the timing of SEP-1, we did not examine whether early measurement of lactate values correlated with compliance with other aspects of the SEP-1 bundle with the exception of antibiotic and fluid administration. Lactate Measurements: A Guide to Therapy or to Quality?CHESTVol. 154Issue 6PreviewWith interest we have read the publication by Han et al1 in CHEST (August 2018) reporting on the relationship between the measurement of lactate levels and outcome in patients with sepsis. The major finding was as follows: the longer it took to measure a first lactate level, the higher the mortality. And so, the authors conclude that systematic early lactate measurements may prompt earlier, potentially life-saving interventions. Full-Text PDF Implications of Centers for Medicare & Medicaid Services Severe Sepsis and Septic Shock Early Management Bundle and Initial Lactate Measurement on the Management of SepsisCHESTVol. 154Issue 2PreviewSepsis remains a significant cause of morbidity and mortality in the United States, leading to the implementation of the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). SEP-1 identifies patients with “severe sepsis” via clinical and laboratory criteria and mandates interventions, including lactate draws and antibiotics, within a specific time window. We sought to characterize the patients affected and to study the implications of SEP-1 on patient care and outcomes. Full-Text PDF