Abstract
Background: The aim of the study was to retrospectively investigate whether parameters of routine point-of-care testing (POCT) predict hospital mortality in critically ill surgical patients on admission to the intensive care unit (ICU).
Methods: Arterial blood analyses of 1551 patients on admission to the adult surgical ICU of the Technical University Munich were reviewed. POCT was performed on a blood gas analyser. The association between acid-base status and mortality was evaluated. Metabolic acidosis was defined by base excess (BE) <–2 mmol/L and, wherever applicable, subdivided into lactic acidosis by lactate >50% of BE, anion gap (AG)-acidosis by AG >16 mmol/L, hyperchloraemic acidosis by chloride >115 mmol/L. Metabolic alkalosis was defined by BE ≥3 mmol/L. Logistic regression analysis identified variables independently associated with mortality.
Results: Overall mortality was 8.8%. Mortality was greater in male patients (p=0.012). Mean age was greater in non-survivors (p<0.0005). Nine hundred and eighty-six patients showed no metabolic acid-base disorder (mortality 7.3%), thereof 26 patients with pCO2 >55 mm Hg (mortality 23.1%). Three hundred and seventy-seven patients presented with acidosis (mortality 11.4%), thereof 163 patients with lactic acidosis (mortality 19%). Mortality for alkalosis (174 patients) was 12.1%. Mean blood glucose level for non-survivors was higher compared to survivors (p<0.0005). Logistic regression analysis identified lactate, glucose, age, male gender as independent predictors of mortality.
Conclusions: Lactate and glucose on ICU admission independently predict mortality. BE and AG failed as prognostic markers. Lactic acidosis showed a high mortality rate implying that lactate levels should be obtained on ICU admission. Prevalence of hyperchloraemic acidosis was low. Metabolic alkalosis was associated with an increased mortality. Further studies on this disturbance and its attendant high mortality are warranted.
References
1. Smith I, Kumar P, Molloy S, Rhodes A, Newman PJ, Grounds RM, et al. Base excess and lactate as prognostic indicators for patients admitted to intensive care. Intensive Care Med 2001;27:74–83.10.1007/s001340051352Search in Google Scholar
2. Hucker TR, Mitchell GP, Blake LD, Cheek E, Bewick V, Grocutt M, et al. Identifying the sick: can biochemical measurements be used to aid decision making on presentation to the accident and emergency department. Br J Anaesth 2005;94:735–41.10.1093/bja/aei122Search in Google Scholar PubMed
3. Husain FA, Martin MJ, Mullenix PS, Steele SR, Elliott DC. Serum lactate and base deficit as predictors of mortality and morbidity. Am J Surg 2003;185:485–91.10.1016/S0002-9610(03)00044-8Search in Google Scholar
4. Kaplan LJ, Kellum JA. Initial pH, base deficit, lactate, anion gap, strong ion difference, and strong ion gap predict outcome from major vascular injury. Crit Care Med 2004;32:1120–4.10.1097/01.CCM.0000125517.28517.74Search in Google Scholar PubMed
5. Whitcomb BW, Pradhan EK, Pittas AG, Roghmann MC, Perencevich EN. Impact of admission hyperglycemia on hospital mortality in various intensive care unit populations. Crit Care Med 2005;33:2772–7.10.1097/01.CCM.0000189741.44071.25Search in Google Scholar PubMed
6. Gunnerson KJ, Saul M, He S, Kellum JA. Lactate versus non-lactate metabolic acidosis: a retrospective outcome evaluation of critically ill patients. Crit Care 2006;10:R22.10.1186/cc3987Search in Google Scholar PubMed
7. Juneja D, Singh O, Dang R. Admission hyperlactatemia: causes, incidence, and impact on outcome of patients admitted in a general medical intensive care unit. J Crit Care 2011;26:316–20.10.1016/j.jcrc.2010.11.009Search in Google Scholar
8. Nichol AD, Egi M, Pettila V, Bellomo R, French C, Hart G, et al. Relative hyperlactatemia and hospital mortality in critically ill patients: a retrospective multi-centre study. Crit Care 2010;14:R25.10.1186/cc8888Search in Google Scholar PubMed
9. Fencl V, Jabor A, Kazda A, Figge J. Diagnosis of metabolic acid-base disturbances in critically ill patients. Am J Resp Crit Care Med 2000;162:2246–51.10.1164/ajrccm.162.6.9904099Search in Google Scholar
10. Fencl V, Leith DE. Stewart’s quantitative acid-base chemistry: applications in biology and medicine. Resp Physiol 1993; 91:1–16.10.1016/0034-5687(93)90085-OSearch in Google Scholar
11. Kellum JA, Kramer DJ, Pinsky MR. Strong ion gap: a methodology for exploring unexplained anions. J Crit Care 1995;10:51–5.10.1016/0883-9441(95)90016-0Search in Google Scholar
12. Cusack RJ, Rhodes A, Lochhead P, Jordan B, Perry S, Ball JA, et al. The strong ion gap does not have prognostic value in critically ill patients in a mixed medical/surgical adult ICU. Intensive Care Med 2002;28:864–9.10.1007/s00134-002-1318-2Search in Google Scholar PubMed
13. Rocktaeschel J, Morimatsu H, Uchino S, Bellomo R. Unmeasured anions in critically ill patients: can they predict mortality? Crit Care Med 2003;31:2131–6.10.1097/01.CCM.0000079819.27515.8ESearch in Google Scholar PubMed
14. Webster NR, Kulkarni V. Metabolic alkalosis in the critically ill. Crit Rev Clin Lab Sci 1999;36:497–510.10.1080/10408369991239286Search in Google Scholar PubMed
15. Demirjian S, Teo BW, Paganini EP. Alkalemia during continuous renal replacement therapy and mortality in critically ill patients. Crit Care Med 2008;36:1513–7.10.1097/CCM.0b013e318170a2f5Search in Google Scholar PubMed
16. Kreutziger J, Wenzel V, Kurz A, Constantinescu MA. Admission blood glucose is an independent predictive factor for hospital mortality in polytraumatised patients. Intensive Care Med 2009;35:1234–9.http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=000267220800011&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f310.1007/s00134-009-1446-zSearch in Google Scholar PubMed
17. Christiansen C, Toft P, Jorgensen HS, Andersen SK, Tonnesen E. Hyperglycaemia and mortality in critically ill patients. A prospective study. Intensive Care Med 2004;30:1685–8.Search in Google Scholar
18. Stead LG, Jain A, Bellolio MF, Odufuye A, Gilmore RM, Rabinstein A, et al. Emergency department hyperglycemia as a predictor of early mortality and worse functional outcome after intracerebral hemorrhage. Neurocrit Care 2010;13:67–74.http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=000279505900011&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f310.1007/s12028-010-9355-0Search in Google Scholar PubMed
19. Sung J, Bochicchio GV, Joshi M, Bochicchio K, Tracy K, Scalea TM. Admission hyperglycemia is predictive of outcome in critically ill trauma patients. J Trauma 2005;59:80–3.10.1097/01.TA.0000171452.96585.84Search in Google Scholar PubMed
20. Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc 2003;78:1471–8.10.4065/78.12.1471Search in Google Scholar PubMed
21. Berkman M, Ufberg J, Nathanson LA, Shapiro NI. Anion gap as a screening tool for elevated lactate in patients with an increased risk of developing sepsis in the emergency department. J Emerg Med 2009;36:391–4.10.1016/j.jemermed.2007.12.020Search in Google Scholar PubMed
22. Martin MJ, FitzSullivan E, Salim A, Brown CV, Demetriades D, Long W. Discordance between lactate and base deficit in the surgical intensive care unit: which one do you trust? Am J Surg 2006;191:625–30.10.1016/j.amjsurg.2006.02.014Search in Google Scholar PubMed
23. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368–77.10.1056/NEJMoa010307Search in Google Scholar PubMed
24. Jansen TC, van Bommel J, Schoonderbeek FJ, Sleeswijk Visser SJ, van der Klooster JM, Lima AP, et al. Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial. Am J Resp Crit Care Med 2010;182:752–61.10.1164/rccm.200912-1918OCSearch in Google Scholar PubMed
25. Adams BD, Bonzani TA, Hunter CJ. The anion gap does not accurately screen for lactic acidosis in emergency department patients. Emerg Med J 2006;23:179–82.10.1136/emj.2005.026096Search in Google Scholar PubMed PubMed Central
26. Chawla LS, Jagasia D, Abell LM, Seneff MG, Egan M, Danino N, et al. Anion gap, anion gap corrected for albumin, and base deficit fail to accurately diagnose clinically significant hyperlactatemia in critically ill patients. J Intensive Care Med 2008;23:122–7.10.1177/0885066607312985Search in Google Scholar PubMed
27. Galla JH. Metabolic alkalosis. J Am Soc Nephrol 2000;11: 369–75.10.1681/ASN.V112369Search in Google Scholar PubMed
28. Wilson RF, Gibson D, Percinel AK, Ali MA, Baker G, LeBlanc LP, et al. Severe alkalosis in critically ill surgical patients. Arch Surg 1972;105:197–203.10.1001/archsurg.1972.04180080051009Search in Google Scholar PubMed
29. Palange P, Carlone S, Galassetti P, Felli A, Serra P. Incidence of acid-base and electrolyte disturbances in a general hospital: a study of 110 consecutive admissions. Rec Prog Med 1990;81:788–91.Search in Google Scholar
30. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab 2002;87:978–82.10.1210/jc.87.3.978Search in Google Scholar PubMed
31. Abdulraof Menesi F, Verzola D, Villaggio B, Russo R, Sofia A, Fontana I, et al. Evaluation of metabolic acidosis in patients with a kidney graft: comparison of the bicarbonate-based and strong ion-based methods. Transplant Proc 2011;43: 1055–62.10.1016/j.transproceed.2011.01.120http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=000291289400029&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f3Search in Google Scholar PubMed
32. Boniatti MM, Cardoso PR, Castilho RK, Vieira SR. Acid-base disorders evaluation in critically ill patients: we can improve our diagnostic ability. Intensive Care Med 2009;35: 1377–82.10.1007/s00134-009-1496-2Search in Google Scholar PubMed
©2013 by Walter de Gruyter Berlin Boston
