Normal-Range Blood Lactate Concentration in Septic Shock Is Prognostic and Predictive

University of British Columbia, Critical Care Research Laboratories, Institute for Heart+Lung Health, St Paul's Hospital, Vancouver, British Columbia, Canada.
Shock (Augusta, Ga.) (Impact Factor: 3.05). 05/2012; 38(1):4-10. DOI: 10.1097/SHK.0b013e318254d41a
Source: PubMed


We hypothesized that lactate levels even within the normal range are prognostic and that low lactate levels predict a beneficial response to vasopressin infusion in septic shock. We conducted a retrospective analysis using the Vasopressin in Septic Shock Trial (VASST) as a derivation cohort (n = 665), then validated using another single-center septic shock cohort, St Paul's Hospital (SPH) cohort (n = 469). Lactate levels were divided into quartiles. The primary outcome variable was 28-day mortality in both cohorts. We used receiver operating characteristic (ROC) curve analysis to compare the prognostic value of lactate concentrations versus Acute Physiology and Chronic Health Evaluation II scores. We then explored whether lactate concentrations might predict beneficial response to vasopressin compared with noradrenaline in VASST. Normal lactate range is less than 2.3 mmol/L. At enrollment, patients in the second quartile (1.4 < lactate < 2.3 mmol/L) had significantly increased mortality and organ dysfunction compared with patients who had lactate ≤ 1.4 mmol/L (quartile 1) (P < 0.0001). Quartile 2 outcomes were as severe as quartile 3 (2.3 ≤ lactate < 4.4 mmol/L) outcomes. Baseline lactate values (ar ea under the ROC curve = 0.63, 0.66; VASST, SPH) were as good as Acute Physiology and Chronic Health Evaluation II scores (area under the ROC curve = 0.66, 0.73; VASST, SPH) as prognostic indicators of 28-day mortality. Lactate concentrations of 1.4 mmol/L or less predicted a beneficial response in those randomized to vasopressin compared with noradrenaline in VASST (P < 0.05). Lactate concentrations within the "normal" range can be a useful prognostic indicator in septic shock. Furthermore, patients whose lactate level is less than or equal to 1.4 mmol/L may benefit from vasopressin infusion.

283 Reads
  • Source
    • "Heart rate reduction considerably lowers cardiac energy demands, thereby creating a better balance between myocardial energy generation and expenditure in conditions of impaired energy production [13]. In addition, sepsis impairs the ability of tissues to extract oxygen so that adenosine triphosphate (ATP) generation from glucose oxidation is supplemented by ATP generation from glycolysis, leading to lactate production [14]. Presence of elevated lactate levels was associated with a significantly increased mortality in patients with vasopressordependent septic shock and this hyperlactatemia represents a persistent perfusion deficit [15]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Purpose. To conduct a meta-analysis evaluating the efficacy of Shenfu injection for treating patients with septic shock when compared with conventional therapy. Methods. Eight databases including Pubmed, EMBASE, Cochrane Library, ISI Web of Science, CNKI, Wanfang, VIP, and CBM were searched up to October 2014. Randomized controlled trials assessing the efficacy of Shenfu injection were identified. Mean arterial pressure, heart rate, lactate, and mortality were included as outcome measurements. Results. We analyzed data from 12 randomized controlled trials involving 904 participants. Compared with conventional therapy, Shenfu injection could further increase the mean arterial pressure at 1 hour (SMD 0.38; 95% CI, 0.01–0.74) and 6 hours (SMD 0.82; 95% CI, 0.03–1.61). Shenfu injection could further normalize heart rate at 6 hours (SMD −0.90; 95% CI, −1.47–0.33) and clear serum lactate at 6 hours (SMD −0.51; 95% CI, −0.70–0.32) and 24 hours (SMD, 0.52; 95% CI, −0.77–0.26). As the endpoint of mortality was not unified, it was not meta-analyzed. Conclusions. Based on the findings in present review, Shenfu injection is more effective than conventional therapy in increasing mean arterial pressure, normalizing heart rate, clearing serum lactate, and reducing mortality. These results should be confirmed in higher level clinical trials in the future.
    Evidence-based Complementary and Alternative Medicine 07/2015; 2015:863149. DOI:10.1155/2015/863149 · 1.88 Impact Factor
  • Source
    • "Elevated levels are also related to impaired hepatic lactate clearance and mitochondrial dysfunction [20]. Several studies have demonstrated that elevated lactate levels are related to mortality in patients with sepsis [55, 56, 57, 58]. In a retrospective study of critically ill patients, serum lactate levels greater than 2 mmol/L on admission were associated with a 1.94-10.89-fold "
    [Show abstract] [Hide abstract]
    ABSTRACT: Sepsis remains a leading cause of death in critically ill patients, despite efforts to improve patient outcome. Thus far, no magic drugs exist for severe sepsis and septic shock. Instead, early diagnosis and prompt initial management such as early goal-directed therapy are key to improve sepsis outcome. For early detection of sepsis, biological markers (biomarkers) can help clinicians to distinguish infection from host response to inflammation. Ideally, biomarkers can be used for risk stratification, diagnosis, monitoring of treatment responses, and outcome prediction. More than 170 biomarkers have been identified as useful for evaluating sepsis, including C-reactive protein, procalcitonin, various cytokines, and cell surface markers. Recently, studies have reported on the usefulness of biomarker-guided antibiotic stewardships. However, the other side of these numerous biomarkers is that no novel single laboratory marker can diagnose, predict, and track the treatment of sepsis. The purpose of this review is to summarize several key biomarkers from recent sepsis studies.
    03/2014; 46(1):1-12. DOI:10.3947/ic.2014.46.1.1
  • Source
    • "Cardiac dysfunction was defined as low cardiac output by adequate volume supply (Cardiac index determined by PiCCO™, Pulsion Medical Systems SE, Feldkirchin, Germany) requiring continuous dobutamine infusion to achieve a cardiac index ≥2.5 during days 0 to 5. Hemodynamic dysfunction was defined as arterial hypotension despite adequate volume supply requiring continuous norepinephrine infusion to achieve a mean arterial pressure ≥65 mmHg during days 0 to 5 [21]. Microcirculatory dysfunction was defined as metabolic acidosis with serum lactate >4.4 mmol/l during days 0 to 5 [22]. Respiratory dysfunction was defined as respiratory insufficiency requiring mechanical ventilation >24 hours during days 0 to 10. Renal dysfunction was defined according to the RIFLE criteria [23]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Liver dysfunction can derive from severe sepsis and might be associated with poor prognosis. However, diagnosis of septic liver dysfunction is challenging due to a lack of appropriate tests. Measurement of maximal liver function capacity (LiMAx test) has been successfully evaluated as a new diagnostic test in liver resection and transplantation. The aim of this study was to evaluate the LiMAx test during sepsis in comparison to biochemical tests and the indocyanin green test (ICG-PDR). We prospectively investigated 28 patients (8 female and 20 male, age range 35 to 80 years) suffering from sepsis on a surgical ICU. All patients received routine resuscitation from septic shock (surgery, fluids, catecholamines, antibiotic drugs). The first LiMAx test and ICG-PDR were carried out within the first 24 hours after onset of septic symptoms, followed by day 2, 5 and 10. Other biochemical parameters and scores determining the severity of illness were measured daily. Clinical outcome parameters were examined after 90 days or at the end of treatment. The population was divided into 2 groups (group A: non-survivors or ICU length of stay (ICU-LOS) >30 days versus group B: survivors and ICU-LOS <30 days) for analysis. Epidemiological baseline characteristics of both groups were similar. Group A patients had significant lower LiMAx and ICG-PDR values than patients in group B. Determination of ICG-PDR by finger probe failed in 14.3% of tests due to insufficient peripheral pulses. Respiratory, renal and hepatic dysfunction (LiMAx and ICG-PDR) were associated with prolonged ICU-LOS. Only LiMAx <100 mug/kg/h and respiratory dysfunction were associated with increased mortality. For LiMAx <100 mug/kg/h receiver operating characteristic-analysis revealed a 100% sensitivity and 77% specificity for death. Sepsis-related hepatic dysfunction can be diagnosed early and effectively by the LiMAx test. The extent of LiMAx impairment is predictive for patient morbidity and mortality. The sensitivity and specificity of the LiMAx test was superior to that of ICG-PDR regarding the prediction of mortality.
    Critical care (London, England) 10/2013; 17(5):R259. DOI:10.1186/cc13089 · 4.48 Impact Factor
Show more