Howell M, Donnino M, Clardy P, et al. Occult hypoperfusion and mortality in patients with suspected infection

Harvard University, Cambridge, Massachusetts, United States
Intensive Care Medicine (Impact Factor: 7.21). 12/2007; 33(11):1892-9. DOI: 10.1007/s00134-007-0680-5
Source: PubMed


To determine, in the early stages of suspected clinically significant infection, the independent relationship of the presenting venous lactate level to 28-day in-hospital mortality.
Prospective, observational cohort study.
Urban, university tertiary-care hospital.
One thousand two hundred and eighty seven adults admitted through the emergency department who had clinically suspected infection and a lactate measurement.
Seventy-three [5.7% (95% CI 4.4-6.9%)] patients died in the hospital within 28 days. Lactate level was strongly associated with 28-day in-hospital mortality in univariate analysis (p<0.0001). When stratified by blood pressure, lactate remained associated with mortality (p<0.0001). Normotensive patients with a lactate level >or=4.0 mmol/l had a mortality rate of 15.0% (6.0-24%). Patients with either septic shock or lactate >or=4.0 mmol/l had a mortality rate of 28.3% (21.3-35.3%), which was significantly higher than those who had neither [mortality of 2.5% (1.6-3.4%), p<0.0001. In a model controlling for age, blood pressure, malignancy, platelet count, and blood urea nitrogen level, lactate remained strongly associated with mortality. Patients with a lactate level of 2.5-4.0 mmol/l had adjusted odds of death of 2.2 (1.1-4.2); those with lactate >or=4.0 mmol/l had 7.1 (3.6-13.9) times the odds of death. The model had good discrimination (AUC=0.87) and was well calibrated.
In patients admitted with clinically suspected infection, the venous lactate level predicts 28-day in-hospital mortality independent of blood pressure and adds significant prognostic information to that provided by other clinical predictors.

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    • "This indicates that in a group of patients with abnormal PVL, agreement with arterial lactate may be poorer than in a group with normal PVL. There are several studies that report prognostic outcomes based on PVL values taken from ED or trauma populations [6] [31] [32] [33] [37]. These data represent a strong evidence base for the use of PVL alone as a predictor of mortality. "
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    ABSTRACT: The evidence for prognostication using lactate is often based on arterial lactate (AL). Arterial sampling is painful and difficult, and carries risks. Studies comparing peripheral venous lactate (PVL) with AL showed little difference but predominantly included patients with normal lactate. The objective of this study was to measure agreement between PVL and AL in patients with elevated venous lactate. This is a retrospective cross-sectional study. Inclusion criteria: ED patients age ≥16, attending from October 2010 to June 2011 inclusive, with PVL ≥2.0mmol/L and AL taken within 1 hour. Exclusion criteria: intravenous fluid prior to or between initial venous and arterial sampling. Primary endpoint: agreement between PVL and AL defined as mean difference ±95% limits of agreement (LOA). The misclassification rate was assessed. N=232. VL median 3.50mmol/L, range 2.00 to 15.00mmol/L. AL median 2.45mmol/L, range 1.0 to 13.2mmol/L. The mean difference±SD between PVL and AL for all patients was 1.06±1.30mmol/L (95%LOA -1.53 to 3.66mmol/L). Using a cut-off of 2mmol/L and 4mmol/L, 36.2% and 17.9% of patients respectively were incorrectly classified as having elevated lactate. We report greater bias between VL and AL with broader LOA than previously documented. This may partly be due to the fact that we studied only patients with abnormal venous values, for whom close agreement would confer greatest clinical significance. The agreement between abnormal PVL and AL is poor and the high rate of misclassification may suggest that PVL is not a good substitute for AL if the venous lactate is abnormal.
    The American journal of emergency medicine 03/2014; 32(6). DOI:10.1016/j.ajem.2014.03.007 · 1.27 Impact Factor
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    • "PCAS or post-resuscitation disease is a sepsis-like syndrome associated with ischemia/reperfusion injury and the inflammation cascade [11,28]. With or without profound arterial hypotension, an elevated serum lactate level can be a hallmark of impaired tissue perfusion in patients with severe sepsis or septic shock [29]. Thus, in a patient with severe sepsis or septic shock, better lactate clearance can be associated with decreased mortality and might arise from more rapid improvement in tissue perfusion. "
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    ABSTRACT: Several methods have been proposed to evaluate neurological outcome in out-of-hospital cardiac arrest (OHCA) patients. Blood lactate has been recognized as a reliable prognostic marker for trauma, sepsis, or cardiac arrest. The objective of this study was to examine the association between initial lactate level or lactate clearance and neurologic outcome in OHCA survivors who were treated with therapeutic hypothermia. This retrospective cohort study included patients who underwent protocol-based 24-hour therapeutic hypothermia after OHCA between January 2010 and March 2012. Serum lactate levels were measured at the start of therapy (0 hours), and after 6 hours, 12 hours, 24 hours, 48 hours and 72 hours. The 6 hour and 12 hour lactate clearance were calculated afterwards. Patients' neurologic outcome was assessed at one month after cardiac arrest; good neurological outcome was defined as Cerebral Performance Category one or two. The primary outcome was an association between initial lactate level and good neurologic outcome. The secondary outcome was an association between lactate clearance and good neurologic outcome in patients with initial lactate level >2.5 mmol/l. Out of the 76 patients enrolled, 34 (44.7%) had a good neurologic outcome. The initial lactate level showed no significant difference between good and poor neurologic outcome groups (6.07 +/-4 .09 mmol/L vs 7.13 +/- 3.99 mmol/L, P = 0.42), However, lactate levels at 6 hours, 12 hours, 24 hours, and 48 hours in the good neurologic outcome group were lower than in the poor neurologic outcome group (3.81 +/- 2.81 vs 6.00 +/- 3.22 P <0.01, 2.95 +/- 2.07 vs 5.00 +/- 3.49 P <0.01, 2.17 +/- 1.24 vs 3.86 +/- 3.92 P <0.01, 1.57 +/- 1.02 vs 2.21 +/- 1.35 P = 0.03, respectively). The secondary analysis showed that the 6-hour and 12-hour lactate clearance was higher for good neurologic outcome patients (35.3 +/- 34.6% vs 6.89 +/- 47.4% P = 0.01, 54.5 +/- 23.7% vs 25.6 +/- 43.7% P <0.01, respectively). After adjusting for potential confounding variables, the 12-hour lactate clearance still showed a statistically significant difference (P = 0.02). The lactate clearance rate, and not the initial lactate level, was associated with neurological outcome in OHCA patients after therapeutic hypothermia.
    Critical care (London, England) 10/2013; 17(5):R260. DOI:10.1186/cc13090 · 4.48 Impact Factor
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    • "Another interesting finding was the association between lactate level and the risk of early death. Although this association could not be tested in an appropriate multinomial analysis because of excessive missing values, high lactate and its non-clearance are clearly associated with mortality (27,32–34). However, this is the first study to show that high lactate is associated with early mortality, even when only non-survivors are considered. "
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    ABSTRACT: To identify the independent variables associated with death within 4 days after the first sepsis-induced organ dysfunction. In this prospective observational study, severe sepsis and septic shock patients were classified into 3 groups: Group 1, survivors; Group 2, late non-survivors; and Group 3, early non-survivors. Early death was defined as death occurring within 4 days after the first sepsis-induced organ dysfunction. Demographic, clinical and laboratory data were collected and submitted to univariate and multinomial analyses. The study included 414 patients: 218 (52.7%) in Group 1, 165 (39.8%) in Group 2, and 31 (7.5%) in Group 3. A multinomial logistic regression analysis showed that age, Acute Physiology and Chronic Health Evaluation II score, Sepsis-related Organ Failure Assessment score after the first 24 hours, nosocomial infection, hepatic dysfunction, and the time elapsed between the onset of organ dysfunction and the sepsis diagnosis were associated with early mortality. In contrast, Black race and a source of infection other than the urinary tract were associated with late death. Among the non-survivors, early death was associated with Acute Physiology and Chronic Health Evaluation II score, chronic renal failure, hepatic dysfunction Sepsis-related Organ Failure Assessment score after 24 hours, and the duration of organ dysfunction. Factors related to patients' intrinsic characteristics and disease severity as well as the promptness of sepsis recognition are associated with early death among severe septic patients.
    Clinics (São Paulo, Brazil) 05/2013; 68(5). DOI:10.6061/clinics/2013(05)02 · 1.19 Impact Factor
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