Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial

Effects of intraoperative adrenergic administration on postoperative hyperlactatemia in open colon surgery: an observational study

Background

Postoperative Hyperlactatemia (PO-HL) is a frequent condition associated with poor prognosis. In recent years, there has been growing evidence that adrenergic stimulation may contribute to increased lactate levels. The use of adrenergic agonists for the control of intraoperative hypotension is frequent, and its impact on the development of PO-HL is unknown.

Objective

To evaluate whether the use of intraoperative adrenergic agents is associated with the occurrence of PO-HL.

Methods

This was a prospective observational study. The inclusion criteria were undergoing elective open colon surgery, being ≥60 years old and signing informed consent. The exclusion criteria were cognitive impairment, unplanned surgery, and anticipated need for postoperative mechanical ventilation. Baseline and intraoperative variables were collected, and arterial lactate data were collected at baseline and every 6 hours postoperatively for 24 hours. Hyperlactatemia was defined as lactate >2.1 mEq.L^-1.

Results

We studied 28 patients, 61% of whom developed hyperlactatemia. The variables associated with PO-HL in the univariate analysis were anesthetic time, the total dose of intraoperative ephedrine, and lower intraoperative central venous oxygen saturation (ScvO₂). Multivariate analysis confirmed the association between the use of ephedrine (p = 0.004), intraoperative hypotension (p = 0.026), and use of phenylephrine (p = 0.001) with PO-HL.

Conclusions

The use of intraoperative ephedrine, phenylephrine and intraoperative hypotension were independently associated with the development of PO-HL. This finding should lead to new studies in this field, as well as a judicious interpretation of the finding of a postoperative increase in lactate levels.

The Prognostic Role of Lactate Concentrations after Aneurysmal Subarachnoid Hemorrhage

Blood lactate concentrations are often used to assess global tissue perfusion in critically ill patients; however, there are scarce data on lactate concentrations after subarachnoid hemorrhage (SAH). We aimed to assess the prognostic role of serial blood lactate measurements on hospital mortality and neurological outcomes at 3 months after SAH. We reviewed all SAH patients admitted to the intensive care unit from 2007 to 2019 and recorded the highest daily arterial lactate concentration for the first 6 days. Patients with no lactate concentration were excluded. Hyperlactatemia was defined as a blood lactate concentration >2.0 mmol/L. A total of 456 patients were included: 158 (35%) patients died in hospital and 209 (46%) had an unfavorable outcome (UO) at 3 months. The median highest lactate concentration was 2.7 (1.8–3.9) mmol/L. Non-survivors and patients with UO had significantly higher lactate concentrations compared to other patients. Hyperlactatemia increased the chance of dying (OR 4.19 (95% CI 2.38–7.39)) and of having UO in 3 months (OR 4.16 (95% CI 2.52–6.88)) after adjusting for confounding factors. Therefore, initial blood lactate concentrations have prognostic implications in patients with SAH; their role in conjunction with other prognostic indicators should be evaluated in prospective studies.

Clinical trials in critical care: can a Bayesian approach enhance clinical and scientific decision making?

Recent Bayesian reanalyses of prominent trials in critical illness have generated controversy by contradicting the initial conclusions based on conventional frequentist analyses. Many clinicians might be sceptical that Bayesian analysis, a philosophical and statistical approach that combines prior beliefs with data to generate probabilities, provides more useful information about clinical trials than the frequentist approach. In this Personal View, we introduce clinicians to the rationale, process, and interpretation of Bayesian analysis through a systematic review and reanalysis of interventional trials in critical illness. In the majority of cases, Bayesian and frequentist analyses agreed. In the remainder, Bayesian analysis identified interventions where benefit was probable despite the absence of statistical significance, where interpretation depended substantially on choice of prior distribution, and where benefit was improbable despite statistical significance. Bayesian analysis in critical care medicine can help to distinguish harm from uncertainty and establish the probability of clinically important benefit for clinicians, policy makers, and patients.

Clinical Utility of Delta Lactate for Predicting Early In-Hospital Mortality in Adult Patients: A Prospective, Multicentric, Cohort Study

One of the challenges in the emergency department (ED) is the early identification of patients with a higher risk of clinical deterioration. The objective is to evaluate the prognostic capacity of ΔLA (correlation between prehospital lactate (pLA) and hospital lactate (hLA)) with respect to in-hospital two day mortality. We conducted a pragmatic, multicentric, prospective and blinded-endpoint study in adults who consecutively attended and were transported in advanced life support with high priority from the scene to the ED. The corresponding area under the receiver operating characteristics curve (AUROC) was obtained for each of the outcomes. In total, 1341 cases met the inclusion criteria. The median age was 71 years (interquartile range: 54–83 years), with 38.9% (521 cases) females. The total 2 day mortality included 106 patients (7.9%). The prognostic precision for the 2 day mortality of pLA and hLA was good, with an AUROC of 0.800 (95% CI: 0.74–0.85; p < 0.001) and 0.819 (95% CI: 0.76–0.86; p < 0.001), respectively. Of all patients, 31.5% (422 cases) had an ΔLA with a decrease of <10%, of which a total of 66 patients (15.6%) died. A lactate clearance ≥ 10% is associated with a lower risk of death in the ED, and this value could potentially be used as a guide to determine if a severely injured patient is improving in response to the established treatment.

COVID-19 PICU guidelines: for high- and limited-resource settings

BACKGROUND

Fewer children than adults have been affected by the COVID-19 pandemic, and the clinical manifestations are distinct from those of adults. Some children particularly those with acute or chronic co-morbidities are likely to develop critical illness. Recently, a multisystem inflammatory syndrome (MIS-C) has been described in children with some of these patients requiring care in the pediatric ICU.

METHODS

An international collaboration was formed to review the available evidence and develop evidence-based guidelines for the care of critically ill children with SARS-CoV-2 infection. Where the evidence was lacking, those gaps were replaced with consensus-based guidelines.

RESULTS

This process has generated 44 recommendations related to pediatric COVID-19 patients presenting with respiratory distress or failure, sepsis or septic shock, cardiopulmonary arrest, MIS-C, those requiring adjuvant therapies, or ECMO. Evidence to explain the milder disease patterns in children and the potential to use repurposed anti-viral drugs, anti-inflammatory or anti-thrombotic therapies are also described.

CONCLUSION

Brief summaries of pediatric SARS-CoV-2 infection in different regions of the world are included since few registries are capturing this data globally. These guidelines seek to harmonize the standards and strategies for intensive care that critically ill children with COVID-19 receive across the world.

IMPACT

At the time of publication, this is the latest evidence for managing critically ill children infected with SARS-CoV-2. Referring to these guidelines can decrease the morbidity and potentially the mortality of children effected by COVID-19 and its sequalae. These guidelines can be adapted to both high- and limited-resource settings.

Recommendations for hemodynamic monitoring for critically ill children-expert consensus statement issued by the cardiovascular dynamics section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

BACKGROUND

Cardiovascular instability is common in critically ill children. There is a scarcity of published high-quality studies to develop meaningful evidence-based hemodynamic monitoring guidelines and hence, with the exception of management of shock, currently there are no published guidelines for hemodynamic monitoring in children. The European Society of Paediatric and Neonatal Intensive Care (ESPNIC) Cardiovascular Dynamics section aimed to provide expert consensus recommendations on hemodynamic monitoring in critically ill children.

METHODS

Creation of a panel of experts in cardiovascular hemodynamic assessment and hemodynamic monitoring and review of relevant literature-a literature search was performed, and recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. The AGREE statement was followed to prepare this document.

RESULTS

Of 100 suggested recommendations across 12 subgroups concerning hemodynamic monitoring in critically ill children, 72 reached "strong agreement," 20 "weak agreement," and 2 had "no agreement." Six statements were considered as redundant after rephrasing of statements following the first round of voting. The agreed 72 recommendations were then coalesced into 36 detailing four key areas of hemodynamic monitoring in the main manuscript. Due to a lack of published evidence to develop evidence-based guidelines, most of the recommendations are based upon expert consensus.

CONCLUSIONS

These expert consensus-based recommendations may be used to guide clinical practice for hemodynamic monitoring in critically ill children, and they may serve as a basis for highlighting gaps in the knowledge base to guide further research in hemodynamic monitoring.

Prehospital lactate clearance is associated with reduced mortality in patients with septic shock

BACKGROUND

Assessment of disease severity in patients with septic shock (SS) is crucial in determining optimal level of care. In both pre- and in-hospital settings, blood lactate measurement is broadly used in combination with the clinical evaluation of patients as the clinical picture alone is not sufficient for assessing disease severity and outcomes.

METHODS

From 15th April 2017 to 15th April 2019, patients with SS requiring prehospital mobile Intensive Care Unit intervention (mICU) were prospectively included in this observational study. Prehospital blood lactate clearance was estimated by the difference between prehospital (time of first contact between the patients and the mICU prior to any treatment) and in-hospital (at hospital admission) blood lactate levels divided by prehospital blood lactate.

RESULTS

Among the 185 patients included in this study, lactate measurement was missing for six (3%) in the prehospital setting and for four (2%) at hospital admission, thus 175 (95%) were analysed for prehospital blood lactate clearance (mean age 70 ± 14 years). Pulmonary, digestive and urinary infections were probably the cause of the SS in respectively 56%, 22% and 10% of the cases. The 30-day overall mortality was 32%. Mean prehospital blood lactate clearance was significantly different between patients who died and those who survived (respectively 0.41 ± 2.50 mmol.l^-1 vs 1.65 ± 2.88 mmol.l^-1, p = 0.007). Cox regression analysis showed that 30-day mortality was associated with prehospital blood lactate clearance > 10% (HRa [CI95] = 0.49 [0.26-0.92], p = 0.028) and prehospital blood lactate clearance < 10% (HRa [CI95] = 2.04 [1.08-3.84], p = 0.028).

CONCLUSION

A prehospital blood lactate clearance < 10% is associated with 30-day mortality increase in patients with SS handled by the prehospital mICU. Further studies will be needed to evaluate if prehospital blood lactate clearance alone or combined with clinical scores could affected the triage decision-making process for those patients.

The Septic Patient

Anesthesiologists are uniquely positioned to facilitate emergent care of patients with sepsis in the perioperative setting. A subset of sepsis patients presents with surgical pathology. Emphasis is on timely intervention with source control, antibiotic therapy, and aggressive resuscitation. Ileus, aspiration, and cardiovascular collapse must be considered when inducing patients with sepsis. Dynamic fluid responsiveness may prove an effective tool in minimizing over-resuscitation. Assessment of circulatory failure and drug therapy involves an understanding of preload, afterload, and contractility. Timely, targeted resuscitation and early source control have persisted and remain fundamental to sepsis care.

Regional citrate anticoagulation vs no-anticoagulation for CRRT in hyperlactatemia patients with increased bleeding risk: A retrospective cohort study

There are controversial opinions on the use of regional citrate anticoagulation (RCA) continuous renal replacement therapy (CRRT) in hyperlactatemia patients with increased bleeding risk. Patients with hyperlactatemia and increased bleeding risk who accepted RCA or no-anticoagulation CRRT in our center were retrospectively included. Eighty patients who underwent RCA-CRRT and 47 patients received no-anticoagulation CRRT were included. Filter lifespan was significantly longer in the RCA group than the no-anticoagulation group (44.5 hours [2-89] vs 24.5 hours [1.5-70], P < .001). The adjusted results demonstrated that patients in the no-anticoagulant group had significantly higher risk of filter failure (HR = 4.765, 95% CI 2.703-8.4, P < .001). Bleeding episodes occurred in 19 (24.1%) and 22 (46.8%) patients in the RCA and no-anticoagulation group, respectively (P = .012). The overall citrate accumulation (CA) rate was 5% in the RCA group. Patient mortality was associated with the comorbidity of hypertension, increased serum lactate level, and increased SOFA score. After matching, the filter lifespan was significantly longer in the RCA group than the no-anticoagulation group. With careful monitoring and timely adjustment, RCA most likely was safe and effective for CRRT in hyperlactatemia patients with increased bleeding risk.

2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.

2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-Cardiotomy Extracorporeal Life Support in Adult Patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.

The role of the serum lactate level at the first admission to the emergency department in predicting mortality

INTRODUCTION

Lactate is an easily measurable laboratory parameter that is considered a potentially useful prognostic marker for determining risk in emergency department patients. The aim of this study was to investigate the role of serum lactate in the patients who were admitted to the emergency department at the time of admission.

METHODS

Patients who were admitted to the emergency department for various reasons between June 2017 and January 2018 were included in the study. Demographic data, laboratory findings, mortality and hospitalization rates of the patients were analyzed. The primary endpoint was determined as the role of serum lactate in predicting mortality, and the secondary endpoint in predicting hospitalization.

RESULTS

Of the 1382 patients, 47.4% (n = 655) were female and 52.6% (n = 727) were male. The mean age of the patients was 60.99 ± 20.04 (18-100) years. In 59.6% (n = 824) of the patients, the most common hypertension (36%) was an additional disease. Mortality was found in 43 (3.1%) patients. It was observed that 20.5% (n = 284) of the patients were hospitalized. The ages of patients with hospitalization and mortality were found to be statistically significant higher than those without hospitalization and without mortality (p = 0.001; p < 0.01). There was no statistically significant difference between the serum lactate measurements of the patients according to hospitalization (p > 0.05). The serum lactate levels of the patients with mortality were found to be statistically significant higher than those without mortality (p = 0.001; p < 0.01). The cut off point for serum lactate level in predicting mortality was found to be ≥3.6 mmol/L. The mortality rate was found to be statistically significant higher in patients with serum lactate level 3,6 mmol/L and above (p = 0,001; p < 0,01).

CONCLUSION

In conclusion, we believe in the light of the findings of our study that the serum lactate level is effective and reliable in the prediction of mortality in patients who present to emergency department for any reason. However, prospective studies with broader patient groups are required in this subject.

Serum Lactate Level Predicts Short-Term and Long-Term Mortality of HBV-ACLF Patients: A Prospective Study

Background

Acute chronic liver failure (ACLF) is a high-mortality disease characterized by rapid deterioration of liver function and multiple organ failure. The aim of this study was to assess the short-term and long-term predictive values of serum lactate in HBV-ACLF patients to facilitate early treatment and thereby improve patient survival.

Methods

We conducted a single-center, observational prospective study of 108 hospitalized patients. Biochemical examination and demographic data were obtained within 24 hours of admission. Logistics analysis was used to determine whether serum levels were independently for prognosis of HBV-ACLF patients. The area under ROC curve evaluates the prediction accuracy compared to the existing score.

Results

Serum lactate levels in nonsurviving patients were significantly higher than those in surviving patients. Logistics analysis demonstrated that serum lactate was an independent risk factor for 28-day, 3-month, and 6-month mortality. ROC curve evaluates the prediction efficiencies of serum lactate for 28-day, 3-month, and 6-month mortality. The AUROCs of new scores by adding lactate (Child-Pugh+ lactate score, MELD+ lactate score, MELD-Na+ lactate score, CLIF-C OF+ lactate score, CLIF-SOFA+ lactate score, CLIF-C ACLF+ lactate score) were superior to those of existing scores, particularly the MELD score and MELD-Na score (P<0.05) at all time points.

Conclusion

Serum lactate can be used as an effective indicator to predict the short-term and long-term mortality in HBV-ACLF patients, and the predictive value of the MELD score and MELD-Na was improved by adjusting for lactate. Lactate testing at admission can be beneficial in prognostic assessment and clinical decision-making.

Association of Different Lactate Indices with 30-Day and 180-Day Mortality in Patients with ST-Segment Elevation Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention: A Retrospective Cohort Study

Background

Admission lactate level has been reported as a useful marker of mortality. In this study, we compared the relative value of different lactate indices to predict survival in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

Methods

This was a retrospective observational study including consecutive patients with STEMI undergoing primary PCI who admitted to the Coronary Care Unit of the First Affiliated Hospital of Wenzhou Medical University between 2014 and 2017. The predictive value of lactate indices for mortality was compared using receiver operator characteristic (ROC) analysis, and DeLong’s test was used to compare the AUC. We compared the AUC between GRACE score and GRACE score + lactate index.

Results

A total of 1080 patients were included. Fifty-nine died in 30 days and 68 died in 180 days. Most lactate indices (Lac_adm, Lac_24max, Lac_24min and Lac_24tw) were significantly lower in survivors (all P<0.001). In Cox proportional hazards model, each lactate index showed as an independent factor of 30-day and 180-day mortality except Lac_Δ. Kaplan–Meier curves demonstrated that the patients of higher lactate indices group had higher rates of mortality (all P<0.0001, except Lac_Δ P=0.0485). In receiver operator characteristic analysis, Lac_24max was significantly larger than Lac_adm(P<0.001) while the AUC value for Lac_adm was similar to Lac_24min and Lac_24tw. Lac_24tw improved the predictive probability of 30-day mortality (P=0.0415). Lac_24max improved the predictive probability of GRACE score for both 30-day and 180-day mortality (P<0.05).

Conclusion

In patients with STEMI undergoing primary PCI, most lactate indices are all associated with 30-day and 180-day mortality except LacΔ. In prediction of both 30-day and 180-day mortality, Lac_24max is superior to Lac_adm and significantly enhances the ability of risk stratification and prognostic evaluation when adding Lac_24max to the GRACE score.

Transcutaneous oxygen pressure-related variables as noninvasive indicators of low lactate clearance in sepsis patients after resuscitation

The transcutaneous oxygen challenge test (OCT) is associated with central venous oxygen saturation and cardiac output index, and has predictive value for prognosis. Whether the change of transcutaneous oxygen pressure (P_tcO₂)-related variables can reflect lactate clearance in sepsis patients is worth studying. We conducted a prospective observational study of 79 patients with sepsis or septic shock in the ICU. Immediately after enrollment, P_tcO₂ monitoring was continuously performed for 6 h. The OCT was performed at enrollment (T0) and the sixth hour (T6). The correlation between lactate clearance and P_tcO₂-related variables such as P_tcO₂ at T6, ΔP_tcO₂ (P_tcO₂ at T6 - P_tcO₂ at T0), ΔP_tcO₂ index (P_tcO₂/PaO₂ at T6 - P_tcO₂/PaO₂ at T0), 10 OCT [(P_tcO₂ after 10 min on FiO₂ of 1.0) - (P_tcO₂ at baseline)], Δ10 OCT (10 OCT at T6 - 10 OCT at T0) was analyzed. The difference of P_tcO₂-related variables was compared between the high and low lactate clearance groups. P_tcO₂ at T6 (r = 0.477, p < 0.001), ΔP_tcO₂ (r = 0.592, p < 0.001), ΔP_tcO₂ index (r = 0.553, p < 0.001) and Δ10 OCT (r = 0.379, p = 0.001) were significantly correlated with the lactate clearance. To discriminate low lactate clearance, the area under the ROC curve was largest for ΔP_tcO₂, which was 0.804. P_tcO₂ at T6, P_tcO₂ index, ΔP_tcO₂, ΔP_tcO₂ index and Δ10 OCT were significantly different between the two different lactate clearance groups. Low lactate clearance in the initial 6 h of resuscitation of septic shock was associated to lower improvements in P_tcO₂-related variables.

Peritonitis-associated hyperlactatemia for evaluating mortality in secondary peritonitis

BACKGROUND

In sepsis, lactate measurements correlate with mortality; however, the role of lactate in predicting mortality in patients of secondary peritonitis is not yet fully established.

METHODS

Data were maintained prospectively on 224 patients of secondary peritonitis over a period of 10 years. Arterial lactate measurements were performed twice in each patient - once, initially on admission (AL_I ) and the other, 24 h after surgery (AL₂₄ ); from these values, percentage lactate clearance was calculated. These lactate indices and other demographic factors were correlated with mortality.

RESULTS

Overall mortality was 16.07% (36 patients) and morbidity was 63.39% (pulmonary complications commonest); preoperative lactate (more than 2.35 mmol/L), 24-h postoperative lactate (more than 2.05 mmol/L), need for vasopressors and mechanical ventilation independently correlated with morbidity and mortality. A simple prognostic scale constructed using cut-off values of AL_I , AL₂₄ , need for vasopressor support and mechanical ventilation showed a sensitivity of 97.22% and specificity of 52.13% for predicting mortality.

CONCLUSION

Preoperative and postoperative arterial lactate levels, need for vasopressors and mechanical ventilation, are independent predictors of mortality. Using these parameters, it may be possible to identify high risk patients that can benefit from early, goal directed therapy to reduce the mortality of secondary peritonitis.

Evaluation of an Anti-Thrombotic Continuous Lactate and Blood Pressure Monitoring Catheter in an In Vivo Piglet Model undergoing Open-Heart Surgery with Cardiopulmonary Bypass

Blood lactate and blood pressure measurements are important predictors of life-threatening complications after infant open-heart surgeries requiring cardiopulmonary bypass (CPB). We have developed an intravascular nitric oxide (NO)-releasing 5-Fr catheter that contains a lactate sensor for continuous in-blood lactate monitoring and a dedicated lumen for third-party pressure sensor attachment. This device has antimicrobial and antithrombotic properties and can be implanted intravascularly. The importance of this design is its ability to inhibit thrombosis, due to the slow release of NO through the surface of the catheter and around the electrochemical lactate sensors, to allow continuous data acquisition for more than 48 h. An in vivo study was performed using six piglets undergoing open-heart surgery with CPB and cardioplegic arrest, in order to mimic intra-operative conditions for infants undergoing cardiac surgery with CPB. In each study of 3 h, two 5-Fr NO-releasing lactate and blood-pressure monitoring catheters were implanted in the femoral vessels (arteries and veins) and the CPB circuitry to monitor changing lactate levels and blood pressures during and immediately after aortic cross-clamp removal and separation from CBP. Electrical signals continuously acquired through the sensors were processed and displayed on the device's display and via Bluetooth to a computer in real-time with the use of a two-point in vivo calibration against blood gas results. The study results show that lactate levels measured from those sensors implanted in the CPB circuit during CPB were comparable to those acquired by arterial blood gas measurements, whereas lactate levels measured from sensors implanted in the femoral artery were closely correlated with those acquired intermittently by blood gas prior to CPB initiation, but not during CPB. Blood pressure sensors attached to one lumen of the device displayed accurate blood pressure readings compared to those measured using an FDA approved pressure sensor already on the market. We recommend that the sensor be implanted in the CPB's circuit to continuously monitor lactate during CPB, and implanted in the femoral arteries or jugular veins to monitor lactate before and after CPB. Blood pressures dramatically drop during CPB due to lower blood flow into the lower body, and we suspect that the femoral arteries are likely collapsing or constricting on the implanted catheter and disrupting the sensor-to-blood contact. This study shows that the device is able to accurately and continuously monitor lactate levels during CPB and potentially prevent post-surgery complications in infants.

Elevated admission lactate levels in the emergency department are associated with increased 30-day mortality in non-trauma critically ill patients

Background

Elevated blood lactate levels were reported as useful predictors of clinical outcome and mortality in critically ill patients. To identify higher-risk patients, this investigation evaluated the relationship between patient mortality and admission lactate levels during the management of non-trauma critically ill patients in the emergency department (ED).

Methods

In this prospective, single centre observational study in a German university ED, all adult patients who were admitted to the ED resuscitation room were evaluated between September 1, 2014 and August 31, 2015. Blood samples for blood gas analysis, including lactate levels, were obtained immediately at admission. Study endpoint was 30-day mortality.

Results

During the study period, 532 patients were admitted to the resuscitation room of the ED. The data of 523 patients (98.3%) were available. The overall 30-day mortality was 34.2%. Patients presenting to the resuscitation room with admission lactate levels < 2.0 mmol/l had a 30-day mortality of 22.7%, while admission lactate levels above 8.0 mmol/l were associated with higher mortality (8.0–9.9 mmol/l: OR: 2.83, 95%CI: 1.13–7.11, p = 0.03, and ≥ 10 mmol/l: OR: 7.56, 95%CI: 4.18–13.77, p < 0.001).

Conclusion

High lactate levels at admission are associated with an increased 24-h and 30-day mortality. These measurements may be used not only to predict mortality, but to help identify patients at risk for becoming critically ill. The breakpoint for mortality may be an ALL ≥8.0 mmol/l.

Using l-Carnitine as a Pharmacologic Probe of the Interpatient and Metabolic Variability of Sepsis

OBJECTIVE

The objective of this review is to discuss the therapeutic use and differential treatment response to Levo-carnitine (l-carnitine) treatment in septic shock, and to demonstrate common lessons learned that are important to the advancement of precision medicine approaches to sepsis. We propose that significant interpatient variability in the metabolic response to l-carnitine and clinical outcomes can be used to elucidate the mechanistic underpinnings that contribute to sepsis heterogeneity.

METHODS

A narrative review was conducted that focused on explaining interpatient variability in l-carnitine treatment response. Relevant biological and patient-level characteristics considered include genetic, metabolic, and morphomic phenotypes; potential drug interactions; and pharmacokinetics (PKs).

MAIN RESULTS

Despite promising results in a phase I study, a recent phase II clinical trial of l-carnitine treatment in septic shock showed a nonsignificant reduction in mortality. However, l-carnitine treatment induces significant interpatient variability in l-carnitine and acylcarnitine concentrations over time. In particular, administration of l-carnitine induces a broad, dynamic range of serum concentrations and measured peak concentrations are associated with mortality. Applied systems pharmacology may explain variability in drug responsiveness by using patient characteristics to identify pretreatment phenotypes most likely to derive benefit from l-carnitine. Moreover, provocation of sepsis metabolism with l-carnitine offers a unique opportunity to identify metabolic response signatures associated with patient outcomes. These approaches can unmask latent metabolic pathways deranged in the sepsis syndrome and offer insight into the pathophysiology, progression, and heterogeneity of the disease.

CONCLUSIONS

The compiled evidence suggests there are several potential explanations for the variability in carnitine concentrations and clinical response to l-carnitine in septic shock. These serve as important confounders that should be considered in interpretation of l-carnitine clinical studies and broadly holds lessons for future clinical trial design in sepsis. Consideration of these factors is needed if precision medicine in sepsis is to be achieved.

Timeline of sepsis bundle component completion and its association with septic shock outcomes

PURPOSE

To assess the impact of the timeline of sepsis bundle completion with clinical outcomes in septic shock.

MATERIALS AND METHODS

We retrospectively studied adult (≥18 years) patients with septic shock from January 1, 2006, through May 31, 2018, who were admitted to the intensive care unit in Mayo Clinic, Rochester. We divided patients into three groups based on the SSC compliant 1) <1h, 2) 1.1 to 3 h, 3) >3 h after the time of septic shock diagnosis.

RESULTS

We enrolled 1052 septic shock patients, among 8% were in group 1, 26% in group 2, and the remaining in group 3. Those who completed all bundle components within 3 h had the lowest 28-day mortality (17.5% vs. 31.4%, p < .001) and higher survival at 90 days (HR = 0.67; 95% CI 0.55-0.80; p < .001). Sepsis bundle completion in <1 h had no significant advantage in 28-day mortality (21.5% vs.15.9%, p = .4) or 90-day survival compared with group 2 (HR = 1.08; 95% CI 0.77-1.53; p = .6).

CONCLUSIONS

We showed an association between the completion of SSC bundle components within three hours with lower mortality or earlier shock reversal. This relationship was not evident when compared to bundle completion in 1 h vs. within 3 h.

[Lactate in emergency medicine]

The basis of all metabolic processes in the human body is the production and metabolism of carriers of energy. Lactate is the end-product of anaerobic glycolysis. Lactate can serve as a substrate for gluconeogenesis and as an oxidation substrate. Hyperlactatemia can be detected as the result of a multitude of acute events (e.g. shock, sepsis, cardiac arrest, trauma, seizure, ischemia, diabetic ketoacidosis, thiamine deficiency, liver failure and intoxication). Hyperlactatemia can be associated with increased mortality, therefore in emergency medicine the search for the cause of hyperlactatemia is just as important as an effective causal treatment. Repetitive measurements of lactate are components of several treatment algorithms as observation of the dynamic development of blood lactate concentrations can help to make a better assessment of the acute medical condition of the patient and to evaluate the effectiveness of the measures undertaken.

Central venous pressure measurement is associated with improved outcomes in septic patients: an analysis of the MIMIC-III database

Purpose

Measurement of central venous pressure (CVP) can be a useful clinical tool. However, the formal utility of CVP measurement in preventing mortality in septic patients has never been proven.

Methods

The Medical Information Mart for Intensive Care III (MIMIC-III) database was searched to identify septic patients with and without CVP measurements. The primary outcome was 28-day mortality. Multivariate regression was used to elucidate the relationship between CVP measurement and 28-day mortality, and propensity score matching (PSM) and an inverse probability of treatment weighing (IPTW) were employed to validate our findings.

Results

A total of 10,275 patients were included in our study, of which 4516 patients (44%) underwent CVP measurement within 24 h of intensive care unit (ICU) admission. The risk of 28-day mortality was reduced in the CVP group (OR 0.60 (95% CI 0.51–0.70; p < 0.001)). Patients in the CVP group received more fluid on day 1 and had a shorter duration of mechanical ventilation and vasopressor use, and the reduction in serum lactate was greater than that in the no CVP group. The mediating effect of serum lactate reduction was significant for the whole cohort (p = 0.04 for the average causal mediation effect (ACME)) and patients in the CVP group with an initial CVP level below 8 mmHg (p = 0.04 for the ACME).

Conclusion

CVP measurement was associated with decreased risk-adjusted 28-day mortality among patients with sepsis and was proportionally mediated through serum lactate reduction.

Continuous lactate monitoring in critically ill patients using microdialysis

INTRODUCTION

Blood lactate is a strong predictor of mortality in critically ill patients. Its monitoring implies repeated measurements. The EIRUS™ system (Maquet Critical Care AB, 17154, Solna, Sweden) is a new device allowing continuous lactate monitoring by intravascular micro dialysis. The present study aimed at assessing the accuracy of the EIRUS™ system in critically ill patients with circulatory failure.

METHODS

An observational cohort study was conducted in Nîmes University Hospital. Eligible patients were those with circulatory failure in which a specific central venous access was put in place by the physician in charge, allowing continuous lactate measurement by the EIRUS™ system. Lactate measurements obtained by the system were compared to lactate from arterial blood samples at H4 and H8 from the calibration, during the first 48hours of shock.

RESULTS

In all, 28 patients were included providing 244 pairs of measures. The Bland-Altman analysis showed a bootstrapped mean bias at H4 of 0.05 and 95% limits of agreement of -0.9 to 1.0mmol/L. At H8 the mean bias was 0.06 and 95% limits of agreement -1.1 to 1.2mmol/L. The global trend agreement [95% CI] for a pre-specified arbitrary threshold of 1mmol/L, defining clinically significant variations, between H0 and H4 and H4 and H8 was 91.6% [85.1; 95.9] and 89.5% [82.3; 94.4], respectively.

CONCLUSION

The EIRUS™ device provided an overall accurate measurement of lactate in critically ill patients with circulatory failure. Detection of lactate variations over time is less precise and technical issues may limit its clinical use.

Different Biomarker Kinetics in Critically Ill Patients with High Lactate Levels

We evaluated the association of the kinetics of interleukin-6 (IL-6), neutrophil gelatinase-associated lipocalin (NGAL), and high-mobility group box 1 (HMGB1) with intensive care unit (ICU) mortality in critically ill patients with hyperlactatemia. This proof-of-concept study was conducted with prospectively enrolled patients admitted to a medical/surgical ICU with hyperlactatemia (lactate levels >4 mmol/L). Blood lactate, IL-6, NGAL, and HMGB1 were measured every 2 h until 6 h post ICU admission. The primary outcome was ICU mortality. Of thirty patients in this study, 14 patients (47%) had sepsis, and the ICU mortality was 47%. IL-6 and NGAL levels were significantly higher in septic patients than in non-septic patients. On kinetic analysis, the lactate levels were significantly decreased in survivors, and the NGAL levels were significantly increased in non-survivors. Among septic patients, a decline in IL-6 levels were observed in survivors. The HMGB1 levels were unchanged in survivors and non-survivors regardless of sepsis complication. Non-septic patients with higher reduction rate of lactate and HMGB1 had the lowest mortality than the others. ICU patients exhibited different kinetic patterns in lactate, NGAL, and IL-6, but HMGB1 did not seem to change over the 6-h duration. Further studies are necessary to evaluate the efficacy of the combination of the inflammatory biomarkers with lactate.

Maternal sepsis

Maternal sepsis is "a life-threatening condition defined as an organ dysfunction caused by an infection during pregnancy, delivery, puerperium, or after an abortion," with the potential to save millions of lives if a proper approximation is made. Undetected or poorly managed maternal infections can lead to sepsis, death, or disability for the mother, and an increased likelihood of early neonatal infection and other adverse outcomes. Physiological, immunologic, and mechanical changes that occur in pregnancy make pregnant women more susceptible to infections than nonpregnant women and may obscure signs and symptoms of infection and sepsis, resulting in a delay in the recognition and treatment of sepsis. Prioritization of the creation and validation of tools that allow the development of clear and standardized diagnostic criteria of maternal sepsis and septic shock, according to the changes inherent to pregnancy, correspond to highly effective strategies to reduce the impact of these conditions on maternal health worldwide. After an adequate diagnostic approach, the next goal is achieving stabilization, trying to stop the progression from sepsis to septic shock, and improving tissue perfusion to limit cell dysfunction. Management protocol implementation during the first hour of treatment will be the most important determinant for the reduction of maternal mortality associated with sepsis and septic shock.

Acidosis predicts mortality independently from hyperlactatemia in patients with sepsis

RATIONALE AND OBJECTIVES

Acidosis and hyperlactatemia predict outcome in critically ill patients. We assessed BE and pH for risk prediction capabilities in a sub-group of septic patients in the MIMIC-III database.

METHODS

Associations with mortality were assessed by logistic regression analysis in 5586 septic patients. Baseline parameters, lactate concentrations, pH, and BE were analyzed at baseline and after 6 hours.

MEASUREMENTS AND MAIN RESULTS

We combined acidosis (defined as either BE ≤-6 and/or pH ≤7.3) and hyperlactatemia and split the cohort into three subgroups: low-risk (no acidosis and lactate <2.3 mmol/L; n = 2294), medium-risk (either acidosis or lactate >2.3 mmol/L; n = 2125) and high-risk (both acidosis and lactate >2.3 mmol/L; n = 1167). Mortality was 14%, 20% and 38% (p<0.001) in low-risk, medium-risk and high-risk patients, respectively. The predictiveness of this model (AUC 0.63 95%CI 0.61-0.65) was higher compared to acidosis (AUC 0.59 95%CI 0.57-0.61; p<0.001) and lactate >2.3 mmol/L (AUC 0.60 95%CI 0.58-0.62; p<0.001) alone. Hyperlactatemia alone was only moderately predictive for acidosis (AUC 0.60 95%CI 0.59-0.62).

CONCLUSIONS

Acidosis and hyperlactatemia can occur independently to a certain degree. Combining acidosis and hyperlactatemia in a model yielded higher predictiveness for ICU-mortality. Septic patients with acidosis should be treated even more aggressively in the future.

Optimal target in septic shock resuscitation

Septic shock presents a high risk of morbidity and mortality. Through therapeutic strategies, such as fluid administration and vasoactive agents, clinicians intend to rapidly restore tissue perfusion. Nonetheless, these interventions have narrow therapeutic margins. Adequate perfusion monitoring is paramount to avoid progressive hypoperfusion or detrimental over-resuscitation. During early stages of septic shock, macrohemodynamic derangements, such as hypovolemia and decreased cardiac output (CO) tend to predominate. However, during late septic shock, endothelial and coagulation dysfunction induce severe alterations of the microcirculation, making it more difficult to achieve tissue reperfusion. Multiple perfusion variables have been described in the literature, from bedside clinical examination to complex laboratory tests. Moreover, all of them present inherent flaws and limitations. After the ANDROMEDA-SHOCK trial, there is evidence that capillary refill time (CRT) is an interesting resuscitation target, due to its rapid kinetics and correlation with deep hypoperfusion markers. New concepts such as hemodynamic coherence and flow responsiveness may be used at the bedside to select the best treatment strategies at any time-point. A multimodal perfusion monitoring and an integrated analysis with macrohemodynamic parameters is mandatory to optimize the resuscitation of septic shock patients.

Frequency of Hyperlactatemia in Intensive Care Patients within Tertiary Care Hospital in Pakistan

Objective

The aim of this study is to determine the frequency of hyperlactatemia in intensive care patients with sepsis in Civil Hospital Karachi.

Method

The cross-sectional study was conducted at a tertiary care hospital for six months and comprised all those participants who were older than 12 years of age, had sepsis, and were admitted in the intensive care unit (ICU) within 24 hours. Participants with suspected secondary acidemia from acute liver failure, end-stage renal disease, on anti-retroviral therapy, an overdose of salicylates, alcohols, acetaminophen, metformin user, intestinal resection, or bacterial overgrowth were excluded from the study. 

Arterial blood samples were collected for lactate levels by the researcher himself, within 24 hours of admission to the ICU. The samples were stored in fluoride tubes and were kept at around four-degree centigrade temperature to avoid any alteration in lactate levels. Demographic details, diagnoses, vitals (blood pressure, heart rate, and respiratory rate) along with lactate levels and criteria for sepsis (including SIRS) of all patients were recorded in the proforma. Lactate level above 1.6 millimoles per liter (mmol/L) was taken as elevated (i.e. hyperlactatemia). SPSS version 16.0 was used for data analysis. Frequency and percentage were calculated for age categories, gender, and hyperlactatemia. Mean, and the standard deviation was calculated for the age of the patient and lactate levels. Effect modifiers were controlled through stratification for age, gender, co-morbidities, and duration of illness. p-value ≤ 0.05 was taken as significant.

Results

A total of 354 patients with sepsis were included in the study. The mean age of the patients was 42.93 (±19.03) years. Out of 354 patients, 169 (47.7%) were males, and 185 (52.3%) were females. Overall, the frequency of hyperlactatemia in intensive care patients with sepsis was 36.4%. The mean value of lactate was 1.963 mmol/L. With respect to stratification for age, hyperlactatemia was more frequent in the elderly patient population (47%) as compared to the young (31%) and middle (30%) aged patients with sepsis (p-value = 0.013). For gender, hyperlactatemia was more frequent in females (39%) than in males (33%). Concerning the duration of illness, hyperlactatemia was more frequent in those patients who were ill for more than one month (80%) than in those who were ill for less than seven days (30%) or 7 to 30-day period (36%) (p-value <0.001). Concerning co-morbidities, hypertension was the most common co-morbid condition in the study population (30%). Hyperlactatemia was significantly frequent in those patients who already had cardiac problem or stroke (66% [p value = 0.003] and 51% [p value = 0.013], respectively).

Conclusion

Hyperlactatemia is a common finding in patients with sepsis in an ICU. Being a marker of hypoxia, lactate level measurements can be of vital importance in a critical care setup, where they can be utilized to determine various factors such as mortality, morbidity, and duration of intensive care. Lactate levels thus should be evaluated in clinical studies, in correlation with various parameters more frequently. Lactate levels can also rise in various conditions apart from sepsis which merits further investigation.

The Added Value of Lactate and Lactate Clearance in Prediction of In-Hospital Mortality in Critically Ill Patients With Sepsis

Supplemental Digital Content is available in the text.

We investigated the added predictive value of lactate and lactate clearance to the Acute Physiology and Chronic Health Evaluation IV model for predicting in-hospital mortality in critically ill patients with sepsis.

Lactate Measurements and Their Association With Mortality in Pediatric Severe Sepsis in India: Evidence That 6-Hour Level Performs Best

PURPOSE

To investigate association of static and dynamic lactate indices with early mortality (within 48 hours of admission), as well as need for vasopressors and mechanical ventilation in pediatric severe sepsis/shock. To explore optimal cutoffs of lactate indices. We hypothesized that dynamic indices are superior to static indices in predicting early mortality.

METHODS

This prospective cohort study involved children (aged <14 years) admitted in emergency department, tertiary care teaching hospital in North India with severe sepsis/shock (2015-2016). Arterial lactate was measured at admission (X0) and after 6 hours (X6). Primary outcome of the measurement was early mortality. Association between lactate indices- lactate at 0 hours (Lac0), lactate after 6 hours (Lac6), time-weighted average (LacTW), delta (ΔLac), clearance (LacCl%) and early mortality, need for vasopressors, and mechanical ventilation-was assessed using Student t test/Mann-Whitney test. Area under the receiver operating characteristic curve (AUROC) for early mortality deduced for all lactate indices and compared with reference (Lac0). Optimal cutoffs (maximizing both sensitivity and specificity) and their positive predictive value (PPV) and negative predictive value (NPV) were determined.

RESULTS

During the study period, 116 children were assessed. Septic shock was present at admission in 56.9% children; 50% of children died during the next 48 hours. Lac0, Lac6, and LacTW were significantly higher, and LacCl% was lower in nonsurvivors versus survivors (all P < .001). Lac6 (0.837 [0.76-0.91]) had significantly higher AUROC (95% confidence interval) than Lac0 (0.77; P = .03). Abnormal lactate metrics (higher Lac0, Lac6, LacTW, and lower LacCl%) were associated with vasopressors need and mechanical ventilation. On logistic regression, Lac6 emerged as an independent predictor of early mortality as well as vasopressor and mechanical ventilation need. The optimal cutoff of Lac6 for identifying early mortality with good sensitivity, specificity, PPV, and NPV was ≥2.65 (76, 85, 83, 78).

CONCLUSIONS

Lactate6 is the best marker associated with early mortality and higher level of care in severe sepsis/septic shock in resource-poor regions.

Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children

OBJECTIVES

To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction.

DESIGN

A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process.

METHODS

The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate.

RESULTS

The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 49 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 52 research priorities were identified.

CONCLUSIONS

A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.

The origins of the Lacto-Bolo reflex: the mythology of lactate in sepsis

The use of lactate as a marker of the severity of circulatory shock was popularized by Dr. Weil in the 1970's. Dr. Weil promoted the idea that blood lactate concentration increased in circulatory shock due to anaerobic metabolism following decreased oxygen delivery. This concept becomes entrenched with 1992 ACCP/SCCM consensus conference definition of sepsis. Since then, the central role of lactate in the definition and management of septic shock has only been expanded and become more ingrained. This review will discuss the wisdom of such an approach, an updated model describing the origins of hyperlactatemia in sepsis, and how such improvements in our knowledge of the underlying physiology should change our approach to resuscitation in patients presenting with septic shock.

Driving blind: instituting SEP-1 without high quality outcomes data

In 2015, the Centers for Medicare and Medicaid Services (CMS) instituted an all-or-none sepsis performance measure bundle (SEP-1) to promote high-quality, cost-effective care. Systematic reviews demonstrated only low-quality evidence supporting most of SEP-1's interventions. CMS has removed some but not all of these unproven components. The current SEP-1 version requires patients with suspected sepsis have a lactate level, blood cultures, broad-spectrum antibiotics and, if hypotensive, a fixed 30 mL/kg fluid infusion within 3 hours, and a repeat lactate if initially elevated within 6 hours. Experts have continued to raise concerns that SEP-1 remains overly prescriptive, lacks a sound scientific basis and presents risks (overuse of antibiotics and inappropriate fluids not titrated to need). To incentivize compliance with SEP-1, CMS now publicly publishes how often hospitals complete all interventions in individual patients. However, compliance measured across hospitals (5 studies, 48-2,851 hospitals) or patients (three studies, 110-851 patients) has been low (approximately 50%) which is not surprising given SEP-1's lack of scientific basis. The largest observational study (1,738 patients) reporting survival rates employing SEP-1 found they were not significantly improved with the measure (P=0.53) as did the next largest study (851 patients, adjusted survival odds ratio 1.36, 95% CI, 0.85 to 2.18). Two smaller observational studies (158 and 450 patients) reported SEP-1 improved unadjusted survival (P≤0.05) but were confounded either by baseline imbalances or by simultaneous introduction of a code sepsis protocol to improve compliance. Regardless, retrospective studies have well known biases related to non-randomized designs, uncontrolled data collection and failure to adjust for unrecognized influential variables. Such low-quality science should not be the basis for a national mandate compelling care for a rapidly lethal disease with a high mortality rate. Instead, SEP-1 should be based on high quality reproducible evidence from randomized controlled trials (RCT) demonstrating its benefit and thereby safety. Otherwise we risk not only doing harm but standardizing it.

Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children

OBJECTIVES

To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction.

DESIGN

A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process.

METHODS

The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate.

RESULTS

The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 52 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 49 research priorities were identified.

CONCLUSIONS

A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.

Inhaled Albuterol Use and Impaired Lactate Clearance in Patients With Sepsis: A Retrospective Cohort Study

BACKGROUND

Lactate clearance has become important in the management of sepsis. However, factors unrelated to sepsis-induced hyperlactatemia, including β-2 adrenergic agonists, can interfere with lactate clearance.

OBJECTIVES

To investigate the association of inhaled albuterol with lactate clearance in patients with sepsis.

METHODS

This was a single-center retrospective cohort study. Adult patients with sepsis diagnosed in the emergency department from May 2015 to May 2016 with initial lactate levels >2 mmol/L and serial lactate measurements 2 to 6 hours apart were included. Patients were divided into 2 groups based on whether they received inhaled albuterol between lactate measurements. The primary end point was lactate clearance of 10%. Secondary end points included intensive care unit (ICU) consultation and in-hospital mortality. A multivariate logistic regression analysis was performed to assess the effect of inhaled albuterol on lactate clearance.

RESULTS

Of 269 patients included, 58 (22%) received inhaled albuterol between lactate measurements. This group had a significantly higher prevalence of pulmonary disease and a lower initial lactate compared to those who did not receive inhaled albuterol. They had a significantly lower rate of lactate clearance (45% vs 77%, P < .001); however, ICU consultation (71% vs 57%, P = .066) and in-hospital mortality (19% vs 22%, P = .64) were not significantly different. A multivariate logistic regression analysis adjusting for age, sex, chronic kidney disease, cirrhosis, cancer, septic shock or severe sepsis, and the amount of intravenous fluids received showed that inhaled albuterol was independently associated with impaired lactate clearance (adjusted odds ratio: 0.26, 95% confidence interval: 0.14-0.50, P < .001).

CONCLUSIONS

Inhaled albuterol in patients with sepsis was associated with impaired lactate clearance without an increase in ICU consultation or in-hospital mortality. Impaired lactate clearance in patients with sepsis who receive inhaled albuterol should be interpreted with caution.

From a pressure-guided to a perfusion-centered resuscitation strategy in septic shock: Critical literature review and illustrative case

PURPOSE

To support a paradigm shift in the management of septic shock from pressure-guided to perfusion-centered, expected to improve outcome while reducing adverse effects from vasopressor therapy and aggressive fluid resuscitation.

MATERIAL AND METHODS

Critical review of the literature cited in support of vasopressor use to achieve a predefined mean arterial pressure (MAP) of 65 mmHg and review of pertinent clinical trials and studies enabling deeper understanding of the hemodynamic pathophysiology supportive of a perfusion-centered approach, accompanied by an illustrative case.

RESULTS

Review of the literature cited by the Surviving Sepsis Campaign revealed lack of controlled clinical trials supporting outcome benefits from vasopressors. Additional literature review revealed adverse effects associated with vasopressors and worsened outcome in some studies. Vasopressors increase MAP primarily by peripheral vasoconstriction and in occasions by a modest increase in cardiac output when using norepinephrine. Thus, achieving the recommended MAP of 65 mmHg using vasopressors should not be presumed indicative that organ perfusion has been restored. It may instead create a false sense of hemodynamic stability hampering shock resolution.

CONCLUSIONS

We propose focusing the hemodynamic management of septic shock on reversing organ hypoperfusion instead of attaining a predefined MAP target as the key strategy for improving outcome.

Arterial blood pressure correlates with 90-day mortality in sepsis patients: a retrospective multicenter derivation and validation study using high-frequency continuous data

OBJECTIVE

To identify the outcome of patients with sepsis using high-frequency blood pressure data.

MATERIALS AND METHODS

This retrospective observational study was conducted at a university hospital ICU (derivation study) and at two urban hospitals (validation study) with data from adult sepsis patients who visited the centers during the same period. The area under the curve (AUC) of blood pressure falling below threshold was calculated. The predictive 90-day mortality (primary endpoint) area under threshold (AUT) and critical blood pressure were calculated as the maximum area under the curve of the receiver operating characteristic curve (AUCROC) and the threshold minus average AUT (derivation study), respectively. For the validation study, the derived 90-day mortality AUCROC (using critical blood pressure) was compared with Sequential Organ Failure Assessment (SOFA), Simplified Acute Physiology Score (SAPS) II, Acute Physiology and Chronic Health Evaluation (APACHE) II, and APACHE III.

RESULTS

Derivation cohort (N = 137): the drop area from the mean blood pressure of 70 mmHg at 24-48 hours most accurately predicted 90-day mortality [critical blood pressure, 67.8 mmHg; AUCROC, 0.763; 95% confidence interval (CI), 0.653-0.890]. Validation cohort (N = 141): the 90-day mortality AUCROC (0.776) compared with the AUCROC for SOFA (0.711), SAPSII (0.771), APACHE II (0.745), and APACHE III (0.710) was not significantly different from the critical blood pressure 67.8 mmHg (P = 0.420).

CONCLUSION

High-frequency arterial blood pressure data of the period and extent of blood pressure depression can be useful in predicting the clinical outcomes of patients with sepsis.

A Case of Linezolid Toxicity Presenting as a Sepsis Mimic

Linezolid is an efficacious and well tolerated antimicrobial but can have serious adverse effects including myelo-suppression, serotonin syndrome, neuropathy, hypoglycemia, liver dysfunction, and lactic acidosis. The side effects are generally duration dependent; linezolid use is not recommended for more than 28 days. Case. A 59-year-old female presented with malaise, loss of appetite, and altered mentation. She had multiple medical comorbidities and required long-term anticoagulation with warfarin for venous thromboembolism. She had multiple medication allergies. Prior to admission, she was on linezolid for cellulitis of foot due to Methicillin-resistant Staphylococcus aureus (MRSA). On physical exam, she was drowsy and required endotracheal intubation for airway protection. Initial laboratory parameters showed lactic acidosis, thrombocytopenia, supra-therapeutic coagulation profile, low blood glucose, and transaminitis. Her altered mentation was due to hypoglycemia. The interaction with warfarin led to altered coagulation profile. She developed shock and vasopressors were initiated. Given her presentation, she was managed as severe sepsis. There were no active infectious foci attributing to decline of her clinical status. Linezolid was discontinued and she was managed with intravenous polymyxin B, aztreonam, and vancomycin. Her hemodynamic status improved within one day. She was extubated on Day 5 of her presentation. Her laboratory parameters showed gradual improvement over 12 days after discontinuation of linezolid. Retrospective evaluation revealed linezolid toxicity as possible cause of presentation. Linezolid toxicity can present as sepsis mimic and should be considered as a differential diagnosis while managing sepsis with other antimicrobial agents.

Prognostic Significance of Arterial Lactate Levels at Weaning from Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation

BACKGROUND

The outcome after weaning from postcardiotomy venoarterial extracorporeal membrane oxygenation (VA-ECMO) is poor. In this study, we investigated the prognostic impact of arterial lactate levels at the time of weaning from postcardiotomy VA.

METHODS

This analysis included 338 patients from the multicenter PC-ECMO registry with available data on arterial lactate levels at weaning from VA-ECMO.

RESULTS

Arterial lactate levels at weaning from VA-ECMO (adjusted OR 1.426, 95%CI 1.157-1.758) was an independent predictor of hospital mortality, and its best cutoff values was 1.6 mmol/L (<1.6 mmol/L, 26.2% vs. ≥ 1.6 mmol/L, 45.0%; adjusted OR 2.489, 95%CI 1.374-4.505). When 261 patients with arterial lactate at VA-ECMO weaning ≤2.0 mmol/L were analyzed, a cutoff of arterial lactate of 1.4 mmol/L for prediction of hospital mortality was identified (<1.4 mmol/L, 24.2% vs. ≥1.4 mmol/L, 38.5%, p = 0.014). Among 87 propensity score-matched pairs, hospital mortality was significantly higher in patients with arterial lactate ≥1.4 mmol/L (39.1% vs. 23.0%, p = 0.029) compared to those with lower arterial lactate.

CONCLUSIONS

Increased arterial lactate levels at the time of weaning from postcardiotomy VA-ECMO increases significantly the risk of hospital mortality. Arterial lactate may be useful in guiding optimal timing of VA-ECMO weaning.

The association between the initial lactate level and need for massive transfusion in severe trauma patients with and without traumatic brain injury

Background

Exsanguination is a major cause of death in severe trauma patients. The purpose of this study was to analyze the prognostic impact of the initial lactate level for massive transfusion (MT) in severe trauma. We divided patients according to subgroups of traumatic brain injury (TBI) and non-TBI.

Methods

This single-institution retrospective study was conducted on patients who were admitted to hospital for severe trauma between January 2016 and December 2017. TBI was defined by a head Abbreviated Injury Scale ≥3. Receiver operating characteristic analysis was used to analyze the prognostic impact of the lactate level. Multivariate analyses were performed to evaluate the relationship between the MT and lactate level. The primary outcome was MT.

Results

Of the 553 patients, MT was performed in 62 patients (11.2%). The area under the curve (AUC) for the lactate level for predicting MT was 0.779 (95% confidence interval [CI], 0.742 to 0.813). The AUCs for lactate level in the TBI and non-TBI patients were 0.690 (95% CI, 0.627 to 0.747) and 0.842 (95% CI, 0.796 to 0.881), respectively. In multivariate analyses, the lactate level was independently associated with the MT (odds ratio [OR], 1.179; 95% CI, 1.070 to 1.299). The lactate level was independently associated with MT in non-TBI patients (OR, 1.469; 95% CI, 1.262 to 1.710), but not in TBI patients.

Conclusions

The initial lactate level may be a possible prognostic factor for MT in severe trauma. In TBI patients, however, the initial lactate level was not suitable for predicting MT.

Thiamine Use in Sepsis: B1 for Everyone?

Every year, sepsis affects nearly 30 million people worldwide, with current annual estimates reporting as many as 6 million deaths. To combat the staggering number of patients who are affected by sepsis, clinicians continue to investigate novel treatment approaches. One treatment approach that has gained interest is the role that vitamins and nutrients play in the body's response to sepsis. Thiamine, in particular, has been studied because of its role in glucose metabolism and lactate production. This review provides a summary of the current literature surrounding the use of thiamine in the treatment of sepsis and describes the function of this essential nutrient in sepsis pathology. We also aim to provide clinicians with the necessary understanding to recognize the potential for thiamine deficiency, as well as detail the role of thiamine supplementation in the treatment of sepsis.

The Impact of Serum Glucose on the Predictive Value of Serum Lactate for Hospital Mortality in Critically Ill Surgical Patients

Background

Lactate has been widely used as a risk indicator of outcomes in critically ill patients due to its ready measurement and good predictive ability. However, the interconnections between lactate metabolism and glucose metabolism have not been sufficiently explored, yet. In this study, we aimed to investigate whether glucose levels could influence the predictive ability of lactate and design a more comprehensive strategy to assess the in-hospital mortality of critically ill patients.

Methods

We analyzed the clinical data of 293 critically ill patients. The primary outcome was in-hospital mortality. The logistic regression analysis and the area under the receiver operating characteristic curve (AUROC) were applied to evaluate the predictive ability of lactate in association with glucose.

Results

The lactate level showed significant association with in-hospital mortality, and its predictive ability was also comparable to other prognostic scores such as the SOFA score and APACHE II score. We further divided 293 patients into three groups based on glucose levels: low-glucose group (<7 mmol/L), medium-glucose group (7-9 mmol/L), and high-glucose group (>9 mmol/L). The lactate level was associated with in-hospital mortality in the low- and high- glucose groups, but not in the medium-glucose group, whereas the SOFA score and APACHE II score were associated with in-hospital mortality in all three glucose groups. The AUROC of lactate in the medium-glucose group was also the lowest among the three glucose groups, indicating a decrease in its predictive ability.

Conclusions

Our findings demonstrated that the predictive ability of lactate to assess in-hospital mortality could be influenced by glucose levels. In the medium glucose level (i.e., 7-9 mmol/L), lactate was inadequate to predict in-hospital mortality and the SOFA score; the APACHE II score should be utilized as a complementation in order to obtain a more accurate prediction.

Significance of Early Postoperative Arterial Lactic Acid, Inferior Vena Cava Variability, and Central Venous Pressure in Hypovolemic Shock

Introduction

Up to one-third of patients admitted to the ICU are in circulatory shock, and early recognition of the condition is vital if subsequent tissue injuries are to be avoided. We would like to know what role the arterial lactic acid, inferior vena cava variability, and CVP (central venous pressure) play in the early stages of shock.

Methods

This is a retrospective study of patients who underwent surgical resuscitation in the Department of Critical Care Medicine. We use the ROC (receiver-operating characteristic) curve to evaluate the significance of each indicator in the diagnosis. For correlation analysis between groups, we first use linear regression for processing and then analysis with correlation.

Results

The ROC curve analysis shows that the area under the curve of the lactic acid group was 0.9272, the area under the curve of the inferior vena cava variability group was 0.8652, and the area under the curve of the CVP group was 0.633. Correlation analysis shows that the inferior vena cava variability and arterial lactic acid Pearson's r = 0.2863 and CVP and arterial lactic acid Pearson's r = 0.0729.

Conclusion

The diagnostic value of arterial lactate is still very high and can still be used as an early warning indicator to help clinicians be alert to the microcirculatory disorders that have emerged quietly. The degree of inferior vena cava variability is linearly related to arterial lactic acid and can also be used as a reference indicator for early evaluation of shock. The diagnostic value of CVP is obviously lower.

Early lactate measurement is associated with better outcomes in septic patients with an elevated serum lactate level

Background

The optimal timing of lactate measurement for septic patients in the intensive care unit (ICU) remains controversial, and whether initiating and repeating the lactate measurement earlier could make a difference for septic patients with an elevated lactate level remains unexplored.

Methods

This was a retrospective observational study that included septic patients with an initial lactate level > 2.0 mmol/L after ICU admission, and all data were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) database. The main exposure of interest was the early lactate measurement, which was defined as an initial lactate level measurement within 1 h after ICU admission. The primary outcome was 28-day mortality.

Results

A total of 2642 eligible subjects were enrolled, including 738 patients who had initial lactate measurements completed within 1 h (EL group) and 1904 patients who had initial lactate measurements completed more than 1 h after ICU admission (LL group). A significant beneficial effect of early lactate measurement in terms of 28-day mortality was observed: the adjusted odds ratio (OR) was 0.69 (95% CI 0.55–0.87; p = 0.001), and the mediation effect of the time to initial vasopressor administration was significant (average causal mediation effect (ACME) − 0.018; 95% CI − 0.005 approximately to − 0.036; p < 0.001). A strong relationship between delayed initial lactate measurement and risk-adjusted 28-day mortality was noted (OR 1.04; 95% CI 1.02–1.05; p < 0.001). Each hour of delay in remeasuring the lactate level was associated with an increase in 28-day mortality in the EL group (OR 1.09; 95% CI 1.04–1.15; p < 0.001). Further analysis demonstrated that repeating the measurement 3 h after the initial lactate measurement led to a significant difference.

Conclusions

Early lactate measurement is associated with a lower risk-adjusted 28-day mortality rate in septic patients with lactate levels > 2.0 mmol/L. A shorter time to the initial vasopressor administration may contribute to this relationship. Repeating the lactate measurement within 3 h after the initial measurement is appropriate for patients whose lactate levels were measured within 1 h of admission.