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01-02-2016 | Original

Severe hyperlactatemia, lactate clearance and mortality in unselected critically ill patients

Authors: Sebastian A. Haas, Theresa Lange, Bernd Saugel, Martin Petzoldt, Valentin Fuhrmann, Maria Metschke, Stefan Kluge

Published in: Intensive Care Medicine | Issue 2/2016

Abstract

Purpose

Hyperlactatemia may occur for a variety of reasons and is a predictor of poor clinical outcome. However, only limited data are available on the underlying causes of hyperlactatemia and the mortality rates associated with severe hyperlactatemia in critically ill patients. We therefore aimed to evaluate the etiology of severe hyperlactatemia (defined as a lactate level >10 mmol/L) in a large cohort of unselected ICU patients. We also aimed to evaluate the association between severe hyperlactatemia and lactate clearance with ICU mortality.

Methods

In this retrospective, observational study at an University hospital department with 11 ICUs during the study period between 1 April 2011 and 28 February 2013, we screened 14,040 ICU patients for severe hyperlactatemia (lactate >10 mmol/L).

Results

Overall mortality in the 14,040 ICU patients was 9.8 %. Of these, 400 patients had severe hyperlactatemia and ICU mortality in this group was 78.2 %. Hyperlactatemia was associated with death in the ICU [odds ratio 1.35 (95 % CI 1.23; 1.49; p < 0.001)]. The main etiology for severe hyperlactatemia was sepsis (34.0 %), followed by cardiogenic shock (19.3 %), and cardiopulmonary resuscitation (13.8 %). Patients developing severe hyperlactatemia >24 h of ICU treatment had a significantly higher ICU mortality (89.1 %, 155 of 174 patients) than patients developing severe hyperlactatemia ≤24 h of ICU treatment (69.9 %, 158 of 226 patients; p < 0.0001). Lactate clearance after 12 h showed a receiver-operating-characteristics area under the curve (ROC-AUC) value of 0.91 to predict ICU mortality (cut-off showing highest sensitivity and specifity was a 12 h lactate clearance of 32.8 %, Youden Index 0.72). In 268 patients having a 12-h lactate clearance <32.8 % ICU mortality was 96.6 %.

Conclusions

Severe hyperlactatemia (>10 mmol/L) is associated with extremely high ICU mortality especially when there is no marked lactate clearance within 12 h. In such situations, the benefit of continued ICU therapy should be evaluated.

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Doherty JR, Cleveland JL (2013) Targeting lactate metabolism for cancer therapeutics. J Clin Investig 123:3685–3692PubMedCentralCrossRefPubMed

Kraut JA, Madias NE (2014) Lactic acidosis. N Engl J Med 371:2309–2319CrossRefPubMed

Saugel B, Trepte CJ, Heckel K, Wagner JY, Reuter DA (2015) Hemodynamic management of septic shock: is it time for ‘individual goal-directed hemodynamic therapy’ and for specifically targeting the microcirculation? Shock 43:522–529CrossRefPubMed

Ince C (2005) The microcirculation is the motor of sepsis. Crit Care 9(Suppl 4):S13–S19PubMedCentralCrossRefPubMed

Vincent JL, De Backer D (2005) Microvascular dysfunction as a cause of organ dysfunction in severe sepsis. Crit Care 9(Suppl 4):S9–S12PubMedCentralCrossRefPubMed

Vincent JL, De Backer D (2013) Circulatory shock. N Engl J Med 369:1726–1734CrossRefPubMed

Barth E, Albuszies G, Baumgart K, Matejovic M, Wachter U, Vogt J, Radermacher P, Calzia E (2007) Glucose metabolism and catecholamines. Crit Care Med 35:S508–S518CrossRefPubMed

Cady LD Jr, Weil MH, Afifi AA, Michaels SF, Liu VY, Shubin H (1973) Quantitation of severity of critical illness with special reference to blood lactate. Crit Care Med 1:75–80CrossRefPubMed

Kaplan LJ, Kellum JA (2004) Initial pH, base deficit, lactate, anion gap, strong ion difference, and strong ion gap predict outcome from major vascular injury. Crit Care Med 32:1120–1124CrossRefPubMed

10.

Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, Jaeschke R, Mebazaa A, Pinsky MR, Teboul JL, Vincent JL, Rhodes A (2014) Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of intensive care medicine. Intensive Care Med 40:1795–1815PubMedCentralCrossRefPubMed

11.

Falk JL, Rackow EC, Leavy J, Astiz ME, Weil MH (1985) Delayed lactate clearance in patients surviving circulatory shock. Acute Care 11:212–215PubMed

12.

Vincent JL, Dufaye P, Berre J, Leeman M, Degaute JP, Kahn RJ (1983) Serial lactate determinations during circulatory shock. Crit Care Med 11:449–451CrossRefPubMed

13.

Marik PE, Bellomo R (2015) Lactate clearance as a target of therapy in sepsis: a flawed paradigm. OA Crit Care 01(1):3

14.

Gu WJ, Zhang Z, Bakker J (2015) Early lactate clearance-guided therapy in patients with sepsis: a meta-analysis with trial sequential analysis of randomized controlled trials. Intensive Care Med 41:1862–1863CrossRefPubMed

15.

Gunnerson KJ, Saul M, He S, Kellum JA (2006) Lactate versus non-lactate metabolic acidosis: a retrospective outcome evaluation of critically ill patients. Crit Care 10:R22PubMedCentralCrossRefPubMed

16.

Nichol AD, Egi M, Pettila V, Bellomo R, French C, Hart G, Davies A, Stachowski E, Reade MC, Bailey M, Cooper DJ (2010) Relative hyperlactatemia and hospital mortality in critically ill patients: a retrospective multi-centre study. Crit Care 14:R25PubMedCentralCrossRefPubMed

17.

Youden WJ (1950) Index for rating diagnostic tests. Cancer 3:32–35CrossRefPubMed

18.

Bakker J, Coffernils M, Leon M, Gris P, Vincent JL (1991) Blood lactate levels are superior to oxygen-derived variables in predicting outcome in human septic shock. Chest 99:956–962CrossRefPubMed

19.

Bernardin G, Pradier C, Tiger F, Deloffre P, Mattei M (1996) Blood pressure and arterial lactate level are early indicators of short-term survival in human septic shock. Intensive Care Med 22:17–25CrossRefPubMed

20.

Marecaux G, Pinsky MR, Dupont E, Kahn RJ, Vincent JL (1996) Blood lactate levels are better prognostic indicators than TNF and IL-6 levels in patients with septic shock. Intensive Care Med 22:404–408CrossRefPubMed

21.

Moomey CB Jr, Melton SM, Croce MA, Fabian TC, Proctor KG (1999) Prognostic value of blood lactate, base deficit, and oxygen-derived variables in an LD50 model of penetrating trauma. Crit Care Med 27:154–161CrossRefPubMed

22.

Schreiber J, Nierhaus A, Vettorazzi E, Braune SA, Frings DP, Vashist Y, Izbicki JR, Kluge S (2014) Rescue bedside laparotomy in the intensive care unit in patients too unstable for transport to the operating room. Crit Care 18:R123PubMedCentralCrossRefPubMed

23.

Khosravani H, Shahpori R, Stelfox HT, Kirkpatrick AW, Laupland KB (2009) Occurrence and adverse effect on outcome of hyperlactatemia in the critically ill. Crit Care 13:R90PubMedCentralCrossRefPubMed

24.

Bakker J, Jansen TC (2007) Dont take vitals, take a lactate. Intensive Care Med 33:1863–1865PubMedCentralCrossRefPubMed

25.

Varpula M, Tallgren M, Saukkonen K, Voipio-Pulkki LM, Pettila V (2005) Hemodynamic variables related to outcome in septic shock. Intensive Care Med 31:1066–1071CrossRefPubMed

26.

Maillet JM, Le Besnerais P, Cantoni M, Nataf P, Ruffenach A, Lessana A, Brodaty D (2003) Frequency, risk factors, and outcome of hyperlactatemia after cardiac surgery. Chest 123:1361–1366CrossRefPubMed

27.

Martin MJ, FitzSullivan E, Salim A, Brown CV, Demetriades D, Long W (2006) Discordance between lactate and base deficit in the surgical intensive care unit: which one do you trust? Am J Surg 191:625–630CrossRefPubMed

28.

Broder G, Weil MH (1964) Excess lactate: an index of reversibility of shock in human patients. Science 143:1457–1459CrossRefPubMed

29.

Juneja D, Singh O, Dang R (2011) Admission hyperlactatemia: causes, incidence, and impact on outcome of patients admitted in a general medical intensive care unit. J Crit Care 26:316–320CrossRefPubMed

30.

Casserly B, Phillips GS, Schorr C, Dellinger RP, Townsend SR, Osborn TM, Reinhart K, Selvakumar N, Levy MM (2015) Lactate measurements in sepsis-induced tissue hypoperfusion: results from the surviving sepsis campaign database. Crit Care Med 43:567–573CrossRefPubMed

31.

Leone M, Bechis C, Baumstarck K, Ouattara A, Collange O, Augustin P, Annane D, Arbelot C, Asehnoune K, Baldesi O, Bourcier S, Delapierre L, Demory D, Hengy B, Ichai C, Kipnis E, Brasdefer E, Lasocki S, Legrand M, Mimoz O, Rimmele T, Aliane J, Bertrand PM, Bruder N, Klasen F, Friou E, Levy B, Martinez O, Peytel E, Piton A, Richter E, Toufik K, Vogler MC, Wallet F, Boufi M, Allaouchiche B, Constantin JM, Martin C, Jaber S, Lefrant JY (2015) Outcome of acute mesenteric ischemia in the intensive care unit: a retrospective, multicenter study of 780 cases. Intensive Care Med 41(4):667–676CrossRefPubMed

32.

Bakker J, Gris P, Coffernils M, Kahn RJ, Vincent JL (1996) Serial blood lactate levels can predict the development of multiple organ failure following septic shock. Am J Surg 171:221–226CrossRefPubMed

33.

Jansen TC, van Bommel J, Mulder PG, Lima AP, van der Hoven B, Rommes JH, Snellen FT, Bakker J (2009) Prognostic value of blood lactate levels: does the clinical diagnosis at admission matter? J Trauma 66:377–385CrossRefPubMed

34.

Nguyen HB, Rivers EP, Knoblich BP, Jacobsen G, Muzzin A, Ressler JA, Tomlanovich MC (2004) Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med 32:1637–1642CrossRefPubMed

35.

Hajjar LA, Almeida JP, Fukushima JT, Rhodes A, Vincent JL, Osawa EA, Galas FR (2013) High lactate levels are predictors of major complications after cardiac surgery. J Thorac Cardiovasc Surgery 146:455–460CrossRef

36.

Kogan A, Preisman S, Bar A, Sternik L, Lavee J, Malachy A, Spiegelstein D, Berkenstadt H, Raanani E (2012) The impact of hyperlactatemia on postoperative outcome after adult cardiac surgery. J Anesth 26:174–178CrossRefPubMed

37.

O’Connor ED, Fraser JF (2010) Hyperlactatemia in critical illness and cardiac surgery. Crit Care 14:421PubMedCentralCrossRefPubMed

38.

Cheung PY, Finer NN (1994) Plasma lactate concentration as a predictor of death in neonates with severe hypoxemia requiring extracorporeal membrane oxygenation. J Pediatr 125:763–768CrossRefPubMed

39.

Sviri S, van Heerden PV (2014) Discussing end-of-life decisions in the ICU-are we doing our best? Crit Care Med 42:1560–1561CrossRefPubMed

40.

Luce JM (2010) End-of-life decision making in the intensive care unit. Am J Respir Crit Care Med 182:6–11CrossRefPubMed

Title: Severe hyperlactatemia, lactate clearance and mortality in unselected critically ill patients
Authors: Sebastian A. Haas
Theresa Lange
Bernd Saugel
Martin Petzoldt
Valentin Fuhrmann
Maria Metschke
Stefan Kluge
Publication date: 01-02-2016
Publisher: Springer Berlin Heidelberg
Published in: Intensive Care Medicine / Issue 2/2016
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-015-4127-0

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Severe hyperlactatemia, lactate clearance and mortality in unselected critically ill patients

Abstract

Purpose

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

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