Serum Lactate Clearance Research Articles

Serum Lactate Clearance as a Predictive Biomarker for Optimal Graft Perfusion in Living Donor Liver Transplantation

BackgroundThe optimal balance between the graft volume (GV) and portal venous flow (PVF) in living donor liver transplantation (LDLT) is unclear. As lactate is mainly metabolized in the liver, perioperative lactate levels are reportedly a useful biomarker for early graft dysfunction (EGD). The present study analyzed perioperative lactate levels according to the PVF. MethodsThe PVF/GV (mL/min per 100 g GV) of 97 recipients from 1996 to 2022 was retrospectively classified as low (LPVF; PVF/GV ≤ 100, N = 29), moderate (MPVF; PVF/GV 100–250, N = 40), or high (HPVF; PVF/GV > 250, N = 28). Lactate levels were obtained preoperatively (L0), immediately after graft reperfusion (L1), 4 h after reperfusion (L2), and on postoperative day 3 (L3). The lactate clearances were then calculated. ResultsThe lower the PVF/GV ratio, the younger the age at LDLT and the higher the graft-to-recipient weight ratio. The median L2 and L3 in the HPVF group were significantly higher than those in the other groups (p = 0.019 and p = 0.003, respectively). The median ΔL1 in the HPVF group was lower than that in the LPVF and MPVF groups (0.23 vs. 0.50, p < 0.0001 and 0.23 vs. 0.41, p = 0.011, respectively). ΔL1 was negatively correlated with the PVF/GV. Although no patient had EGD, three patients with HPVF with low ΔL1 developed small-for-size syndrome. ConclusionsGraft hyperperfusion may delay the recovery of the graft function and result in poor lactate clearance. The combination of the PVF/GV and lactate clearance may be useful as a prognostic marker for optimal graft perfusion in LDLT. Level of evidenceIV.

Feasibility and Outcomes of a Cardiovascular Medicine Inclusive Extracorporeal Membrane Oxygenation (ECMO) Service

BackgroundThere has been a significant increase in the utilization of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in recent years. Cardiothoracic surgery teams have historically led VA-ECMO care teams, with little data available on alternative care models. MethodsWe performed a retrospective review of a cardiovascular medicine inclusive VA-ECMO service, analyzing patients treated with peripheral VA-ECMO at a large quaternary care center from 2018 to 2022. The primary outcome was death while on VA-ECMO or within 24 hours of decannulation. Univariate and multivariate analyses were used to identify predictors of the primary outcome. ResultsTwo hundred forty-four patients were included in the analysis (median age 61 years; 28.7% female), of whom 91.8% were cannulated by interventional cardiologists, and 84.4% were managed by a cardiology service comprised of interventional cardiologists, cardiac intensivists or advanced heart failure cardiologists. Indications for VA-ECMO included acute myocardial infarction (34.8%), decompensated heart failure (30.3%), and refractory cardiac arrest (10.2%). VA-ECMO was utilized during cardiopulmonary resuscitation in 26.6% of cases, 48% of which were peri-procedural arrest. Of the patients, 46% survived to decannulation, the majority of whom were decannulated percutaneously in the cardiac catheterization laboratory. There was no difference in survival following cannulation by a cardiac surgeon vs interventional cardiologist (50% vs 45%; P = .90). Complications included arterial injury (3.7%), compartment syndrome (4.1%), cannulation site infection (1.2%), stroke (14.8%), acute kidney injury (52.5%), access site bleeding (16%) and need for blood transfusion (83.2%). Elevated baseline lactate (odds ratio [OR], 1.13 per unit increase) and sequential organ failure assessment score (OR, 1.27 per unit increase) were independently associated with the primary outcome. Conversely, an elevated baseline survival after VA ECMO score (OR, 0.92 per unit increase) and 8-hour serum lactate clearance (OR, 0.98 per % increase) were independently associated with survival. ConclusionsThe use of a cardiovascular medicine inclusive ECMO service is feasible and may be practical in select centers as indications for VA-ECMO expand.

Role of Serum Lactate Clearance as a Predictor of Mortality and Morbidity in Neonatal Sepsis: A Prospective Cohort Study

Introduction: Neonatal sepsis is a global healthcare concern, which is more prevalent in developing countries. However, surprisingly, biomarkers with good sensitivity and specificity to predict mortality and morbidity are lacking. Higher levels of serum lactate are observed in patients exposed to an inflammatory response, but its practical use remains limited. Therefore, the author aimed to investigate the relationship between serum lactate measurements and the severity of neonatal sepsis. Aim: To assess the role of serum lactate clearance as a marker to predict mortality and morbidity in neonatal sepsis. Additionally, the secondary aim was to evaluate the demographic profile of neonatal sepsis and understand the relationship between C-reactive Protein (CRP), Procalcitonin, and lactate clearance in neonatal sepsis. Materials and Methods: A prospective cohort study was conducted in the Sick Newborn Care Unit (SNCU) and Neonatal Intensive Care Unit (NICU) of Chittaranjan Seva Sadan, College of Obstetrics, Gynaecology, and Child Health in Kolkata, India, from June 2020 to May 2021. A total of 93 confirmed cases of neonatal sepsis were included in the study. Serum lactate levels were measured at the time of sepsis diagnosis and 48 hours after the first sample. Lactate clearance was calculated, and the neonates were followed till discharge or death. Various parameters, including complete blood count, CRP, Procalcitonin, culture, and Cerebrospinal Fluid (CSF), were assessed. The data obtained were statistically analysed using paired t-test, one-way Analysis of Variance (ANOVA), and Pearson’s Chi-square test. Results: A total of 93 neonates were included after meeting the inclusion and exclusion criteria. Among them, 10 neonates died, while 83 were successfully discharged. It was found that death was significantly associated (p&lt;0.0001) with lactate clearance. Total 9 (90%) of the deceased neonates had negative lactate clearance, while only 21 (25.3%) discharged neonates had negative lactate clearance. Lactate clearance was also significantly associated with the duration of hypoglycaemia (p=0.008), duration of Nil Per Mouth (NPM) (p=0.01), and need for reintubation (p=0.05). However, no association was found with the duration of hospital stay, duration of fluid therapy, duration of oxygen requirement, and need for ventilation. Conclusion: Lactate clearance showed a significant association with the risk of mortality in patients with neonatal sepsis. Therefore, lactate clearance can be used as a prognostic marker to identify sepsis. Early detection of sepsis can aid in proper management and subsequently reduce mortality

A comparison of the changes in serum lactate between surgical repair and transthoracic device closure of ventricular septal defects in pediatric patients.

The purpose of this study was to compare the changes in serum lactate between surgical repair and transthoracic device closure of ventricular septal defects (VSDs) in pediatric patients. This study was a retrospective analysis, and 314 pediatric patients with simple VSD from October 2019 to October 2021 were selected. The patients were divided into the S group (surgical repair) and the D group (transthoracic device closure). The serum lactate value at ICU admission and 6 h after operation, as well as the highest serum lactate value were collected, and the 6-h serum lactate clearance rate was calculated. Through propensity score matching, 43 pairs of cases were successfully matched. Compared with the S group, the D group had a shorter operation duration, ventilation duration, and ICU duration, as well as a lower drainage volume and total hospitalization cost. There was no significant difference between the two groups in the initial and highest serum lactate values after VSD closure, while the 6-h serum lactate value in the D group was significantly lower than that in the S group, and the 6-h serum lactate clearance rate in the D group was five times faster than that in the S group. In addition, the 6-h serum lactate clearance rate in the S group was mainly related to the operation time, CPB time, and ventilation time, while the 6-h serum lactate clearance rate in the D group was only related to the operation time. The initial and highest serum lactate levels were not significantly different between surgical repair and transthoracic device closure of VSD, but the 6-h serum lactate clearance rate of device closure was five times faster than that of surgical repair.

Study of Early Lactate Clearance as an Independent Predictor of Survival in Patients with Presumed Sepsis

&#x0D; Aim: Measurement of serial serum lactate levels in patients presenting with sepsis and correlating with 1. early lactate clearance with mortality. 2. Early lactate clearance vs. first (baseline) lactate level in mortality prediction. 3. Early lactate clearance vs. ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION II score in mortality prediction. 4. Early lactate clearance vs. non lactate clearance in mortality prediction.&#x0D; Place and Duration of Study: Department of General Medicine, SMIMER, Surat, Gujarat between December 1st 2017 and November 25th 2019.&#x0D; Methodology: 50 patients (36 male, 14 females; age more than 18 years) Patient with sepsis were selected from Medicine ICU by using ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION II score ≥ 12 points. Lactate levels at 0, 6, 12, 24 and 48 hours were measured by using ABG done by ABL 800 basic analyzer. ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION II score was calculated on admission. Lactate clearance was calculated (&lt;10% OR &gt;10%) and was correlated with mortality (&lt; 7 days or &gt; 7 days).&#x0D; Results: Among 50 patients studied, 39 patients were in lactate clearance group and 11 patients were in lactate non-clearance group. In lactate clearance group 35 (89%) patients survived and 4 (11%) patients expired. In lactate non-clearance group 9 (81%) patients expired and 2 (19%) patients survived. On observing the lactate trend, Serial serum lactate levels were decreasing in survived patients while serial serum lactate levels were static or increasing in expired patients. There was no correlation between serum lactate at 0 hour and mortality in the study group (p value &gt; 0.05). There was correlation between serum lactate at 6, 12, and 24 hours with mortality (p value &lt;0.05). There was strong correlation between serum lactate clearance and mortality (p value &lt; 0.01).&#x0D; Conclusion: Study confirmed the prognostic value of serial serum lactate monitoring and its clearance for prediction of mortality. We concluded that early lactate clearance could be used as an independent predictor of survival in patients with presumed sepsis.&#x0D; &#x0D;

Serum lactate clearance as a predictor of outcome in infants' postcardiac surgery

Background and Aims: Prediction of postoperative outcomes by conventional hemodynamic parameters and risk scoring systems immediately after pediatric cardiac surgery has not been found to be reliable. Trends in serum lactate value over time or serum lactate clearance were found to give better estimate. The present study aimed to find out the effect of serum lactate clearance on mortality after pediatric cardiac surgery. Methods: Out of the 150 pediatric cardiac surgical procedures performed during the study period, 131 patients meeting inclusion criteria were enrolled in the present study. The study population was observed for lactate levels immediately postoperatively (T0) and then every 4 h for the first 24 h (T1-T6) and lactate clearance was calculated. Patient's outcomes in view of mortality, duration of mechanical ventilation, and length of intensive care unit (ICU) stay were observed. Results: In our study, mortality was 9.23%. Median inter quartile range with Hodges-Lehmann median difference (95% confidence interval) lactate values were higher among nonsurvivors and statistically significant at T0 = (6.14 [3.43,7.34] vs. 2.50 [1.87,3.59]; 2.53 [1.02, 4.33], P ≤ 0.0001), T1 = (3.10 [2.81, 5.16] vs. 2.30 [1.73, 3.61];0.95 [0.13, 1.73], P = 0.032), T2 = (3.49 [3.03, 5.40] vs. 2.39 [1.66, 3.38];1.32 [0.48, 2.27], P = 0.004), T3 = (3.82 [2.99, 5.54] vs. 2.20 [1.58, 3.45]; 1.46 [0.50, 2.45], P = 0.003), T4 = (4.86 [3.35, 5.44] vs. 2.09 [1.42, 3.47]; 2.02 [1.09, 3.13], P ≤ 0.0001), T5 = (4.36 [3.80, 6.27] vs. 2 [1.32, 3.26]; 2.29 [1.41, 3.25], P ≤ 0.0001), and T6 = (4.12 [3.69, 5.83] vs. 1.82 [1.31, 3.15]; 2.34 [1.15, 3.21], P ≤ 0.0001). Nonsurvivors were having decreasing trend of lactate clearance which was statistically nonsignificant. Mechanical ventilation was prolonged in nonsurvivors compared to survivor (135 [202] h vs. 30 [77] h; P = 0.002); however, there was no significant difference in ICU stay (P = 0.764). Conclusion: Poor lactate clearance and high lactate level were associated with high mortality. Serial lactate levels and decreasing trend of lactate clearance in the early postoperative period is a good predictor of postoperative outcome in pediatric cardiac surgery.

Normal Saline Solution or Lactated Ringer's Solution to Enhance Lactate Clearance in Septic Patients After Initial Resuscitation in the ED: A Retrospective Cohort Trial.

ObjectiveTo compare the effect of isotonic crystalloid solutions between lactated Ringer’s solution (LRS) and normal saline solution (NSS) on lactate clearance in septic patients at the emergency department (ED).Materials and MethodsThis study is a single-center retrospective chart review. The study enrolled patients older than 18 years with sepsis and initial serum lactate level >2 mg/dL in the ED. The primary outcome was to determine which isotonic solution was better for serum lactate clearance in septic patients. The secondary outcomes were serum creatinine change within 24 h and the 48-h survival rate after admission.ResultsA total of 120 patients were enrolled with a median crystalloid volume administered in the ED of 1000 mL. Within 2 h of resuscitation, there was no difference in lactate clearance between the LRS and NSS groups with median values of 29.2% and 25%, respectively (P=0.839). The 48-h survival rate after admission did not differ between the LRS and NSS groups with median values of 90% and 86%, respectively. Both isotonic solutions increased serum creatinine levels within 24 h of treatment with median values of 0.3 for each group (P=0.647).ConclusionAmong septic patients in the ED treated with NSS or LRS, there was no difference in lactate clearance, serum creatinine change within 24 h, or 48-h survival. However, several factors were associated with increased lactate levels, such as older age and use of vasopressors and immunosuppressive agents.

Renal resistive index as a predictor of postoperative complications in liver resection surgery. Observational study.

Mortality after liver surgery reduced during the last three decades to less than 2%, but post-operative morbidity occurs in 20-50% of cases. Patients are often considered eligible for post-operative intensive-care unit (ICU) admission. Predicting which patients that are at higher risk could lead to a more precise perioperative management. We investigated whether renal resistive index (RRI), alone or along with other items, can predict post-operative complication after hepatic resection. All consecutive patients undergoing hepatectomy for primary or metastatic neoplasm at our Institution between February 2015 and March 2017 were enrolled. They received RRI measurement before entering in operative room and after awakening from general anesthesia. 183 Patients were enrolled. High surgical invasiveness, surgery time > 360min, pre-operative RRI and postoperative serum lactate clearance < - 6%, showed to be associated with postoperative complications. Pre-operative RRI, complex liver resection, long-lasting surgery and poor lactate clearance (cLac) close to awakening from general anesthesia, all together may permit to classify the risk of post-operative adverse outcome after hepatic resection surgery.

2997Prognostic relevance of serum lactate clearance in critically ill patients admitted to ICU

2997Prognostic relevance of serum lactate clearance in critically ill patients admitted to ICU

Persistent Lactic Acidosis during Therapeutic Hypothermia for Hypoxic-Ischemic Encephalopathy Predicts Adverse Outcome

Background: Prolonged lactic acidosis (LA) correlates with severe cerebral injury in asphyxiated animal models. Few studies have evaluated LA and lactate clearance in neonates undergoing therapeutic hypothermia (TH) for hypoxicischemic encephalopathy (HIE). We hypothesize that delayed normalization of serum lactate during TH reflects a more severe cerebral injury. Objective: To determine whether degree of LA prior to initiation of TH, as well as serum lactate clearance and time to normalization of serum lactate level during TH, can …

P2776Unloading the mystery: serum lactate clearance used as an early prognostic marker for survival in severe cardiogenic shock requiring impella support

P2776Unloading the mystery: serum lactate clearance used as an early prognostic marker for survival in severe cardiogenic shock requiring impella support

Looking a “metabolic watch”. The analytical parameters found at the beginning of the resuscitation are predictors of the neurological prognostic in the prehospital cardiac arrest

Purpose of the study: Cardiac arrest (CA) is an important cause of death and disability. With the standardized use of target temperature management and on going sedation for 48–72h, early prognostication after CA is a challenge. The pathophysiology of post CA syndrome is a systemic ischemia/reperfusion response called sepsis-like syndrome.1 Early serum lactate clearance (LC) and lower serum lactate levels have been shown to be associated with decreased mortality in a diverse set of critical illnesses2: why don’t use LC as a prognostic factor of neurological outcome? We analysed the reliability of serum LC as a predictor in patients treated with therapeutic hypothermia after out of hospital CA. Material and methods: through a retrospective analysis of 60 patients admitted to our ICU, we analysed the lactate-level (mg/dl) at ICU admission and after 24h, thenweevaluated the lactate clearance. The LC was calculated as follows: 24-h LC (%) = (0h lactate−24h lactate)/0h lactate×100. Neurological outcome has been evaluated at 6 month using the Pittsburgh Cerebral Performance Category Scale (CPC). Results: themedian value of lactate at T0was26.35 (15.9–65.1); the median value of lactate at T24 was 17.3 (10.15–24.6). 32 patients had a good neurological outcome (CPC 1–2). 28 patients had a bad neurological outcome (CPC 3–5). In the CPC1-2 group the median LC was 73% (−10% to 179%), in the CPC3-5 group the median LCwas 74% (17%–114%). The comparison of LC between the two group showed a p-value of 0.7 Conclusions: there is no correlation for LC in the first 24h after CA between both groups. This conclusion is in contrast with current evidence based in literature.3 Despite Lactacidemia is a sign of microcirculatory damage, our study shows that LC cannot be used to predict the neurological outcome.

Towards a less invasive approach to the early goal-directed treatment of septic shock in the ED

IntroductionEarly goal-directed therapy (EGDT) in septic shock defined by Rivers et al was proven to reduce mortality and validated by observational studies. However, criticism is centered in particular on the early requirement of a central venous catheter (CVC) and on central venous pressure (CVP) as an indicator of volume responsiveness. The present study is a pivotal study to investigate the reliability of a less invasive approach, which uses inferior vena cava (IVC) and lung ultrasounds (US) to guide the infusion of fluids and lactate clearance to monitor tissue perfusion. MethodsWe enrolled 51 patients with septic shock. As a marker of preload optimization, we measured IVC collapse in place of CVP and serum lactate clearance in place of central venous oxygen saturation as a marker of tissue perfusion. As outcomes, we considered the accomplishment of the noninvasive EGDT goals, the number of patients treated without the need of a CVC, the amount of fluids administered in the first 6 hours, the development of pulmonary edema, and the overall mortality rate. ResultsInferior vena cava US evaluation resulted feasible in 92% of patients. Lung US was performed in 100% of cases. In the first 6 hours, only 61.7% of patients received a CVC, an average of 5.5 L of crystalloids were administered, and only 4 patients developed clinical overt pulmonary edema. Mortality was 34% at 28 days and 38.3% at 60 days. ConclusionsOur approach to resuscitation in septic shock appears feasible in the emergency department and needs further study with a randomized controlled trial.

1068

Introduction: To examine the independent predictive value of reaching a central venous oxygen saturation (ScvO2) of 70% or greater among emergency department (ED) patients with severe sepsis or septic shock treated with early goal-directed therapy (EGDT). Methods: Retrospective analysis of a prospective database of 2894 patients with severe sepsis or septic shock treated with EGDT in 21 EDs between March 2010 and September 2012. Patients were included if they qualified for ScvO2-guided therapies as defined by two consecutive ScvO2 measurements less than 70% at least 15 minutes apart with a concomitant CVP of at least 8 mmHg and a MAP of at least 65 mmHg. Variables abstracted during the first six hours of EGDT included age, gender, initial ScvO2, final ScvO2, highest CVP, initial serum lactate, percent serum lactate clearance, mechanical ventilation, shock index, vasopressor or dobutamine administration, red blood cell (RBC) transfusion, lowest hemoglobin, 6-hour Sequential Organ Failure Assessment (SOFA) score and a modified electronic Simplified Acute Physiology Score III (eSAPS 3). Multivariable logistic regression was used to assess the predictive value of each variable on the outcome of in-hospital mortality. Results: 580 (20%) patients were included. In-hospital mortality was 21%. Patients with in-hospital mortality were older(p-0.001), more likely to require mechanical ventilation (p<0.001) or vasopressors (p=0.02), had higher initial serum lactates (p<0.001), 6-hour SOFA (P<0.001) and eSAPS 3 scores (p<0.001), and had lower percentage serum lactate clearances (p=0.002). On logistic regression analysis (c statistic = 0.75), variables associated with the outcome were 6-hour SOFA (OR = 1.14 [1.03-1.26], p=0.014), eSAPS 3 (OR = 1.06 [1.02-1.10], p=0.007), initial lactate (OR = 1.15 [1.03-1.27], p=0.005) and lactate clearance less than 50% (OR = 1.90 [1.03-3.51], p=0.04). Dobutamine administration, RBC transfusion, initial ScvO2 or final ScvO2 were not statistically associated with the outcome before or after adjustment for covariates. Conclusions: When CVP and MAP goals were reached, successful resuscitation to an ScvO2 of 70% or greater was not an independent predictor of in-hospital mortality in this adjusted retrospective analysis. These findings suggest that lactate clearance may be an alternate resuscitation endpoint in this cohort.

Clinical and biochemical outcomes for additive mesenteric and lower body perfusion during hypothermic circulatory arrest for complex total aortic arch replacement surgery

Surgical repair of transverse aortic arch aneurysms frequently employ hypothermia and antegrade cerebral perfusion as protective strategies during circulatory arrest. However, prolonged mesenteric and lower limb ischemia can lead to significant lactic acidosis and end organ dysfunction, which remains a significant cause of post-operative morbidity and mortality. We report our experience with additive warm mesenteric and lower body perfusion (1-3 L/min, 30°C) in addition to continuous cerebral and myocardial perfusion in 5 patients who underwent total aortic arch replacement with trifurcated head vessel re-implantation and distal elephant trunk reconstruction. Concomitant surgical procedures included re-operations (2), aortic root operations (2), coronary artery bypass (2) and descending thoracic aortic replacement (1). Serum lactate levels demonstrated a rapid decline from a peak 9.9 ± 2.6 post circulatory arrest to 3.4 ± 2.0 in the intensive care unit (ICU). The lowest serum bicarbonate levels were 19.3 ± 3.5 mmol/L, intra-operatively, which normalized to 28.4 ± 2.4 mmol/L on return to the ICU. The lowest pH levels were 7.25 ± 0.10, corrected to 7.43 ± 0.04 on return to the ICU. Mean cardiopulmonary bypass and aortic cross-clamp times were 361 ± 104 and 253 ± 85 minutes, respectively. Mean cerebral and lower body circulatory arrest times were 0 (0) and 50 ± 35 minutes, respectively. The mean time required for systemic rewarming was 95 ± 66 minutes. There were no in-hospital mortalities and no patient experienced any neurological, mesenteric, renal or lower limb ischemic complications. Two patients required mechanical ventilation >24 hours, and one patient returned for reoperation for bleeding. Median intensive care unit and total hospital lengths of stay were 5 and 16 days, respectively. Our results suggest early serum lactate clearance, normalization of acidosis, and metabolic recovery when utilizing a simultaneous cerebral perfusion and warm body protection strategy for complex aortic arch surgery. This additive perfusion strategy may attenuate visceral and lower body ischemia that normally develops during periods of deep hypothermic circulatory arrest.