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Agrawal S, Smith M, Berg R, Hoskins IA. Serum Lactate Level as a Predictor for Blood Transfusion in Postpartum Hemorrhage. Am J Perinatol 2023; 40:1798-1802. [PMID: 34808683 DOI: 10.1055/s-0041-1740009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality. At present, there are no reliable clinical or laboratory indicators to identify which patients might require blood transfusions during a PPH. Serum lactate has long been used as an early biomarker of tissue hypoperfusion in trauma settings. The aim of this study is to understand serum lactate's role in the management of obstetric hemorrhage. STUDY DESIGN A retrospective chart review was performed of women who delivered between 2016 and 2019 at our institution and experienced a PPH. The patients were divided into two groups: those with a normal serum lactate level, defined as ≤2 mmol/L, and those with an abnormal serum lactate level, defined as >2 mmol/L. Need for packed red blood cell transfusion, as part of the resuscitation, was assessed for both groups. RESULTS During the study period, 938 women experienced PPH. Of these, 108 (11.5%) had a normal serum lactate, ≤2 mmol/L, and 830 (88.5%) had an abnormal lactate, >2 mmol/L. Women with elevated lactate levels were more likely to receive a blood transfusion versus those with a normal lactate level (57.0 vs. 46.3%, p = 0.035, respectively). Additionally, the average number of blood transfusions administered was significantly higher in the abnormal lactate group versus in the normal lactate group (1.34 vs. 0.97, respectively, p = 0.004). In a multivariable linear regression model, increasing serum lactate levels were found to be predictive of requiring more than 1 unit of blood (p < 0.001). CONCLUSION Women with elevated serum lactate levels were more likely to require blood transfusions during a PPH versus those with a normal serum lactate level. Thus, serum lactate levels are useful as an early indicator of requirement for blood transfusion in the management of obstetric hemorrhage. KEY POINTS · Lactate is a biomarker for blood transfusion in trauma.. · Lactate's role in PPH is unknown.. · Elevated lactate predicts receiving more blood transfusions..
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Affiliation(s)
- Surbhi Agrawal
- Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, New York
| | - Maria Smith
- Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, New York
| | - Robert Berg
- Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, New York
| | - Iffath A Hoskins
- Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, New York
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Li D, Liu S, Zhang J, Cheng W, Mao J, Cui N. Exploring dynamic change in arterial base excess with patient outcome and lactate clearance in the intensive care unit by hierarchical time-series clustering. Front Med (Lausanne) 2022; 9:1020806. [DOI: 10.3389/fmed.2022.1020806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/19/2022] [Indexed: 11/10/2022] Open
Abstract
BackgroundHyperlactatemia is common in the intensive care unit (ICU) and relevant to prognosis, while the process of lactate normalization requires a relatively long period. We hypothesized that the dynamic change in base excess (BE) would be associated with ICU mortality and lactate clearance.MethodsWe performed a retrospective cohort study of adult patients with hyperlactatemia admitted to the ICU from 2016 to 2021. The patients were divided into two groups according to whether the peak BE in 12 h was reached in the first 6 h. We compared ICU mortality and lactate clearance at 6 and 12 h after ICU admission.ResultsDuring the study period, 1,608 patients were admitted to the ICU with a lactate concentration of >2.0 mmol/L and stayed in the ICU for >24 h. The mortality rate was 11.2%. The patients were divided into two groups according to whether the peak BE was reached in the first 6 h following ICU admission: Peak BE12h ≤ 6h and Peak BE12h > 6h. The patients were also recorded as whether bicarbonate treatment was received (bicarbonate group, CRRT included) or not (non-bicarbonate group). Furthermore, lactic acid clearance patterns were identified by time-series clustering (TSC) using various algorithms and distance measures. We compared ICU mortality and lactate clearance at 6 and 12 h after ICU admission with logistic regression. After adjustment for other confounding factors, we found that Peak BE12h > 6h was independently associated with ICU mortality with an odds ratio of 2.231 (p = 0.036) in the bicarbonate group and 2.359 (p < 0.005) in the non-bicarbonate group. In addition, based on the definition of >10% lactate clearance at 6 h or >30% at 12 h, we found that Peak BE12h ≤ 6h had 85.2% sensitivity and 38.1% specificity for effective lactate clearance. In time-series clustering analysis, four categories were discriminated, and pattern of lactic acid clearance reveals the early prognostic value of BE in clearance of lactic acid.ConclusionA prolonged time to reaching the peak BE was independently associated with ICU mortality. In patients with hyperlactatemia, Peak BE12h ≤ 6h could be used as an indicator to predict effective lactate clearance.
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Baron BJ, Nguyen A, Stefanov D, Shetty A, Zehtabchi S. Clinical value of triage lactate in risk stratifying trauma patients using interval likelihood ratios. Am J Emerg Med 2017; 36:784-788. [PMID: 29032876 DOI: 10.1016/j.ajem.2017.10.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 10/07/2017] [Indexed: 10/18/2022] Open
Abstract
Emergency physicians face the challenge of rapidly identifying high-risk trauma patients. Lactate (LAC) is widely used as a surrogate of tissue hypoperfusion. However, clinically important values for LAC as a predictor of mortality are not well defined. OBJECTIVES 1. To assess the value of triage LAC in predicting mortality after trauma. 2. To compute interval likelihood ratios (LR) for LAC. METHODS Retrospective chart review of trauma patients with a significant injury mechanism that warranted labs at an urban trauma center. OUTCOME In-hospital mortality. Data are presented as median and quartiles or percentages with 95% confidence intervals. Groups (lived vs. died) were compared with Man-Whitney-U or Fisher's-exact test. Multivariate analysis was used to measure the association of the independent variables and mortality. The interval likelihood ratios were calculated for all LAC observed values. RESULTS 10,575 patients; median age: 38 [25-57]; 69% male; 76% blunt; 1.1% [n=119] mortality. LAC was statistically different between groups in univariate (2.3 [1.6,3.0] vs 2.8 [1.6,4.8], p=0.008) and multivariate analyses (odds ratio: 1.14 [1.08-1.21], p=0.0001). Interval ratios for LR- ranged from 0.6-1.0. Increasing LAC increased LR+. However, LR+ for LAC reached 5 with LAC>9mmol/L and passed 10 (moderate and conclusive increase in disease probability, respectively) with LAC>18mmol/L. CONCLUSIONS In a cohort of trauma patients with a wide spectrum of characteristics triage LAC was statistically able to identify patients at high risk of mortality. However, clinically meaningful contribution to decision-making occurred only at LAC>9. LAC was not useful at excluding those with a low risk of mortality.
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Affiliation(s)
- Bonny J Baron
- Department of Emergency Medicine, State University of New York, Downstate Medical Center and Kings County Hospital, Brooklyn, NY, USA
| | - Andrew Nguyen
- Department of Emergency Medicine, State University of New York, Downstate Medical Center and Kings County Hospital, Brooklyn, NY, USA
| | - Dimitre Stefanov
- Research Division, Statistical Design & Analysis, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Amit Shetty
- Department of Emergency Medicine, State University of New York, Downstate Medical Center and Kings County Hospital, Brooklyn, NY, USA
| | - Shahriar Zehtabchi
- Department of Emergency Medicine, State University of New York, Downstate Medical Center and Kings County Hospital, Brooklyn, NY, USA.
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Aduen JF, Burritt MF, Murray MJ. Blood Lactate Accumulation: Hemodynamics and Acid Base Status. J Intensive Care Med 2016. [DOI: 10.1177/0885066602017004004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The authors evaluated the relationship between blood lactate accumulation and hemodynamics in a prospective controlled animal study. Seven healthy pigs were anesthetized and mechanically ventilated with a 0.6 fraction of inspired oxygen to achieve a normal PaCO2. Catheters for blood sampling, lactate infusion, and hemodynamic assessment were inserted into the femoral vein and femoral artery. Bolus infusions (466 µmol • kg— 1 over 1 minute) of a neutral solution of sodium lactate were given at 0, 30, 60, and 90 minutes. Each bolus was followed by continuous infusion of the same lactate solution (31.7 µmol • kg— 1 • min—1 after the first, with the rate doubled after each subsequent bolus). Arterial blood samples were drawn at baseline and at 30, 60, 90, and 120 minutes, with simultaneous hemodynamic assessment. Significant increases were seen in blood lactate (from 1.6 ± 0.4 mmol/L at baseline to 4.4 ± 0.8 at 30 minutes, 8.0 ± 1.0 at 60 minutes, and 14.4 ± 2.1 at 90 minutes), pH (from 7.40 ± 0.03 to 7.44 ± 0.05 at 30 minutes, 7.50 ± 0.05 at 60 minutes, and 7.56 ± 0.04 at 90 minutes), and HCO3 — (from 28 ± 1.4 mmol/L to 30 ± 0.7 at 30 minutes, 34 ± 0.9 at 60 minutes, and 37 ± 1.2 at 90 minutes). PaCO2 decreased significantly from 44 ± 3 torr at baseline to 40 ± 4.7 torr at 90 minutes. Blood pressure decreased after each lactate bolus, recovering within 2 minutes initially but not after later injections. Cardiac output, heart rate, and glucose increased significantly, mean arterial pressure and systemic vascular resistance decreased, and stroke volume did not change. Thus, the accumulation of blood lactate due to exogenous administration of a neutral solution of sodium lactate was associated with significant systemic vasodilation, increased cardiac output, increased heart rate, and metabolic alkalosis.
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Affiliation(s)
- Javier F. Aduen
- Division of Pulmonary Medicine, Mayo Clinic, Jacksonville, FL
| | - Mary F. Burritt
- Division of Clinical Biochemistry and Immunology, Mayo Clinic, Rochester, MN
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Siyam FF, Klachko DM. What is hypercalcemia? The importance of fasting samples. Cardiorenal Med 2013; 3:232-8. [PMID: 24474951 DOI: 10.1159/000355526] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 09/09/2013] [Indexed: 01/16/2023] Open
Abstract
The differentiation between primary or tertiary (both hypercalcemic) and secondary (normocalcemic) hyperparathyroidism requires the identification of hypercalcemia. Calcium in the blood exists as bound, complexed and ionized fractions. Calcium sensors on parathyroid cells interact only with the ionized fraction (about 50% of the total calcium concentration). Many formulas using albumin, total protein or phosphate to correct or adjust total calcium to reflect the level of ionized calcium may be accurate only within a limited range. In addition, they can introduce errors based on inaccuracies in the measurement of these other metabolites. Clinical conditions, mainly those illnesses affecting acid-base balance, can alter the proportions of bound and free calcium. How and when the blood samples are drawn can alter the level of total calcium. Prolonged standing or prolonged venous stasis causes hemoconcentration, increasing the bound fraction. Preceding exercise can also affect blood calcium levels. Ingestion of calcium supplements or calcium-containing nutrients can cause transient elevations in blood calcium levels lasting several hours, leading to unnecessary further testing. Fasting total calcium levels may be sufficient for monitoring progress. However, for diagnostic purposes, fasting ionized calcium levels should be used. Therefore, for an isolated high total calcium level, we recommend obtaining a repeat fasting total and ionized calcium measurement before further investigations. Hypercalcemia may be diagnosed if there are persistent or frequent total or, preferably, ionized calcium levels >3 SD above the mean of the normal range or if there are progressively rising levels.
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Affiliation(s)
- Fadi F Siyam
- Cosmopolitan International Diabetes and Endocrinology Center, University of Missouri Health Sciences Center, Columbia, Mo., USA ; Harry S. Truman Memorial VA Hospital, Columbia, Mo., USA
| | - David M Klachko
- Cosmopolitan International Diabetes and Endocrinology Center, University of Missouri Health Sciences Center, Columbia, Mo., USA ; Harry S. Truman Memorial VA Hospital, Columbia, Mo., USA
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Lorne E, Mahjoub Y, Guinot PG, Fournier Y, Detave M, Pila C, Ben Ammar A, Labont B, Zogheib E, Dupont H. Respiratory variations of R-wave amplitude in lead II are correlated with stroke volume variations evaluated by transesophageal Doppler echocardiography. J Cardiothorac Vasc Anesth 2012; 26:381-6. [PMID: 22459928 DOI: 10.1053/j.jvca.2012.01.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The authors hypothesized that variations in electrocardiographically derived R-wave amplitude might be correlated with mechanical ventilation-induced variations in stroke volume as determined by transesophageal echocardiography. DESIGN Observational prospective study. SETTING Single university hospital. PARTICIPANTS Thirty-four patients undergoing coronary artery bypass surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Respiratory R-wave variations in lead II (ΔRII) were correlated with aortic velocity time integral variations (r = 0.82, p < 0.0001). Respiratory R-wave variations in leads III and aVF and pulse pressure variation also were correlated with aortic velocity time integral variations (r = 0.49, p = 0.015; r = 0.61, p = 0.0016; and r = 0.72, p < 0.0001, respectively). R-wave respiratory variations in lead V(5) were not correlated with aortic velocity time integral variations. ΔRII was correlated with pulse pressure variation (r = 0.71, p < 0.0001). A ΔRII cutoff value of 15% accurately predicted stroke volume variations >15%, with a specificity of 92%, a sensitivity of 86%, a positive likelihood ratio of 11.1, a negative likelihood ratio of 0.15, a positive predictive value of 95%, and a negative predictive value of 80%. CONCLUSIONS ΔRII is correlated with stroke volume variations as determined by transesophageal echocardiography in mechanically ventilated patients and can identify the stroke volume variation cutoff of 15%, previously determined to be the cutoff for volume responsiveness.
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Affiliation(s)
- Emmanuel Lorne
- Pôle Anesthésie-Réanimation, CHU d'Amiens, Amiens, France.
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Abstract
BACKGROUND : The intra- and postoperative monitoring of lactate and acid-base has been advocated in pediatric cardiac critical care as surrogate markers of cardiac output, oxygen delivery, and cellular perfusion. Many clinicians use lactate and base excess routinely as markers of tissue perfusion and to assess the effectiveness of their intervention. This review discusses the strengths and weaknesses of using these measurements in pediatric cardiac critical care. METHODOLOGY : A search of MEDLINE, EMBASE, PubMed, and the Cochrane Database was conducted to find controlled trials of lactate and base excess. Adult and pediatric data were considered. Guidelines published by the Society of Critical Care Medicine, the American Heart Association, the American Academy of Pediatrics, and the International Liaison Committee on Resuscitation were reviewed including further review of references cited. RESULTS AND CONCLUSIONS : Many factors other than tissue hypoxia may contribute to hyperlactemia in critical illness. Although the presence of hyperlactemia on admission appears to be associated with intensive care unit mortality and morbidity in some retrospective analyses, significant overlap between survivors and nonsurvivors means that nonsurvivors cannot be predicted from admission lactate measurement. Persistently elevated postoperative lactate is associated with increased morbidity and mortality in the pediatric cardiac population. To date there is no randomized control trial of goal-directed therapy in adult or pediatric cardiac care that includes normalization of lactate as a target. Overall equivalent time measurements of base excess, anion gap, and pH have a low predictive value for morbidity and mortality in children after cardiac surgery. Lactate is one of a cluster of markers of cellular perfusion and oxygen delivery. Alone, as a single measurement, it has minimal predictive value and is nondiscriminatory for survival.
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Makay O, Kaya T, Firat O, Sozbilen M, Caliskan C, Gezer G, Uyar M, Ersin S. ω-3 Fatty Acids Have No Impact on Serum Lactate Levels After Major Gastric Cancer Surgery. JPEN J Parenter Enteral Nutr 2011; 35:488-92. [DOI: 10.1177/0148607110386611] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Ozer Makay
- Department of General Surgery, Ege University, School of Medicine, Bornova-Izmir, Turkey
| | - Tayfun Kaya
- Department of General Surgery, Ege University, School of Medicine, Bornova-Izmir, Turkey
| | - Ozgur Firat
- Department of General Surgery, Ege University, School of Medicine, Bornova-Izmir, Turkey
| | - Murat Sozbilen
- Department of General Surgery, Ege University, School of Medicine, Bornova-Izmir, Turkey
| | - Cemil Caliskan
- Department of General Surgery, Ege University, School of Medicine, Bornova-Izmir, Turkey
| | - Gulten Gezer
- Department of General Surgery, Ege University, School of Medicine, Bornova-Izmir, Turkey
| | - Mehmet Uyar
- Department of Anesthesiology, Ege University, School of Medicine, Bornova-Izmir, Turkey
| | - Sinan Ersin
- Department of General Surgery, Ege University, School of Medicine, Bornova-Izmir, Turkey
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Morton AR, Garland JS, Holden RM. Is the Calcium Correct? Measuring Serum Calcium in Dialysis Patients. Semin Dial 2010; 23:283-9. [DOI: 10.1111/j.1525-139x.2010.00735.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Blood lactate monitoring in critically ill patients: a systematic health technology assessment. Crit Care Med 2009; 37:2827-39. [PMID: 19707124 DOI: 10.1097/ccm.0b013e3181a98899] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To decide whether the use of blood lactate monitoring in critical care practice is appropriate. We performed a systematic health technology assessment as blood lactate monitoring has been implemented widely but its clinical value in critically ill patients has never been evaluated properly. DATA SOURCE PubMed, other databases, and citation review. STUDY SELECTION We searched for lactate combined with critically ill patients as the target patient population. Two reviewers independently selected studies based on relevance for the following questions: Does lactate measurement: 1) perform well in a laboratory setting? 2) provide information in a number of clinical situations? 3) relate to metabolic acidosis? 4) increase workers' confidence? 5) alter therapeutic decisions? 6) result in benefit to patients? 7) result in similar benefits in your own setting? 8) result in benefits which are worth the extra costs? DATA EXTRACTION AND SYNTHESIS We concluded that blood lactate measurement in critically ill patients: 1) is accurate in terms of measurement technique but adequate understanding of the (an)aerobic etiology is required for its correct interpretation; 2) provides not only diagnostic but also important prognostic information; 3) should be measured directly instead of estimated from other acid-base variables; 4) has an unknown effect on healthcare workers' confidence; 5) can alter therapeutic decisions; 6) could potentially improve patient outcome when combined with a treatment algorithm to optimize oxygen delivery, but this has only been shown indirectly; 7) is likely to have similar benefits in critical care settings worldwide; and 8) has an unknown cost-effectiveness. CONCLUSIONS The use of blood lactate monitoring has a place in risk-stratification in critically ill patients, but it is unknown whether the routine use of lactate as a resuscitation end point improves outcome. This warrants randomized controlled studies on the efficacy of lactate-directed therapy.
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Blood lactate monitoring in critically ill patients: A systematic health technology assessment *. Crit Care Med 2009. [DOI: 10.1097/00003246-200910000-00022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Maciel AT, Park M. Differences in acid-base behavior between intensive care unit survivors and nonsurvivors using both a physicochemical and a standard base excess approach: a prospective, observational study. J Crit Care 2009; 24:477-83. [PMID: 19327958 DOI: 10.1016/j.jcrc.2009.01.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2008] [Revised: 11/20/2008] [Accepted: 01/11/2009] [Indexed: 12/12/2022]
Abstract
PURPOSE This study aimed to test the hypothesis that intensive care unit survivors and nonsurvivors differ with regard to type and severity of acid-base disorders. MATERIALS AND METHODS Prospective, observational, cohort study of 107 consecutive patients admitted in a 7-bed intensive care unit during a 6-month period that stayed at least 4 days. All acid-base variables for the first 3 days and the day of discharge were analyzed. RESULTS Survivors had significant metabolic acidosis upon admission, which was due to hyperlactatemia, an excess of unmeasured anions, and principally, hyperchloremia. A progressive decrease in these anions in the presence of constant hypoalbuminemia led to normal standard base excess at discharge. Nonsurvivors had greater metabolic acidosis upon admission with acidifying variables in similar proportions to that of the survivors. On the day of death, nonsurvivors had a similar degree of metabolic acidosis but a different proportion of the anions (less chloride and more lactate) compared with the day of admission. Unmeasured anions were greater in nonsurvivors both on the day of admission and on the day of death. CONCLUSIONS Intensive care unit survivors and nonsurvivors differed in the severity of metabolic acidosis; however, the proportion of the different anions causing the acidosis on admission was similar between these 2 groups.
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Affiliation(s)
- Alexandre Toledo Maciel
- Intensive Care Unit, Department of Medical Emergencies, Hospital das Clínicas, São Paulo, Brazil
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Akkose S, Ozgurer A, Bulut M, Koksal O, Ozdemír F, Ozguç H. Relationships between markers of inflammation, severity of injury, and clinical outcomes in hemorrhagic shock. Adv Ther 2007; 24:955-62. [PMID: 18029320 DOI: 10.1007/bf02877699] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This study was performed to investigate the relationships between markers of inflammation in serum (interleukin-6 [IL-6], interleukin-10 [IL-10], and granulocyte elastase [GE]), severity of injury, and clinical outcomes, and to evaluate the predictive value of these markers for major complications and mortality. This study, which was conducted between August 2003 and May 2005, examined patients older than 16 y who were admitted to the Emergency Unit of the Uludag University Medical School within 12 h after trauma, and who had traumatic hemorrhagic shock (THS) at admission. Three groups were established: the THS group (n=20), the pure hemorrhagic shock (PHS) group (n=20), and the healthy control group (n=20). Demographic data were recorded for all subjects, and blood samples were taken for lactate, base excess, GE, IL-6, and IL-10 measurements. The Glasgow Coma Score, the Revised Trauma Score, the Injury Severity Score, the New Injury Severity Score, and the Trauma Score-Injury Severity Score were calculated; complications and final clinical outcomes were monitored. A total of 35 men and 25 women were included in the study; mean patient age was 41+/-17 y. In the THS group, scores were as follows: Revised Trauma Score, 10.2+/-2.2; Trauma Score-Injury Severity Score, 0.86+/-0.2; Injury Severity Score, 24.8+/-9.0; and New Injury Severity Score, 32.7+/-9.0. IL-6, IL-10, lactate, and base excess levels in the THS group were significantly higher than those in the PHS and healthy control groups. The serum GE level of the THS group was significantly higher than that of the healthy control group, but it did not differ significantly from that of the PHS group. Complications such as sepsis, acute respiratory distress syndrome, and multiple organ failure occurred in 50% of the THS group and in 20% of the PHS group. Mortality was 30% in the THS group and 10% in the PHS group. In the THS group, no significant differences were noted between markers of inflammation and trauma scores of patients who died and those who survived. The investigators concluded that although the levels of markers of inflammation increased in THS patients, they were inadequate for predicting mortality and the development of complications such as acute respiratory distress syndrome, multiple organ failure, and sepsis. A larger study based on the use of serial marker measurements is warranted.
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Affiliation(s)
- Sule Akkose
- Department of Emergency Medicine, Uludag University Medical School, Bursa, Turkey.
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Maciel AT, Park M. Unmeasured anions account for most of the metabolic acidosis in patients with hyperlactatemia. Clinics (Sao Paulo) 2007; 62:55-62. [PMID: 17334550 DOI: 10.1590/s1807-59322007000100009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2006] [Accepted: 10/09/2006] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To characterize the different components of metabolic acidosis in patients with hyperlactatemia in order to determine the degree to which lactate is responsible for the acidosis and the relevance that this might have in the outcome of these patients. METHODS Arterial blood gas, arterial lactate, Na+, K+, Ca2+, Mg2+, Cl-, phosphate, albumin, and creatinine were measured on admission to make a diagnosis of the acid-base disturbances present. Intensive Care Unit and in-hospital mortality were also recorded. RESULTS A total of 58 patients with hyperlactatemia were included. They usually had a mild acidemia (pH 7.31 +/- 0.12) and a significantly high Standard Base Deficit (7.6 +/- 6.7 mEq/L). In addition to lactate (4.3 +/- 2.3 mEq/L), chloride (106.9 +/- 9.5 mEq/L) and unmeasured anions (8.6 +/- 5.0 mEq/L) accounted for the metabolic acidosis. Unmeasured anions were primarily responsible for the acidosis in both Intensive Care Unit survivors and nonsurvivors (44.7% +/- 26.0% and 46.0% +/- 17.5%, respectively, P = 0.871). Lactate contributed in similar percentages to the acidosis in both groups (23.0% +/- 11.8% and 24.2% +/- 9.7% in Intensive Care Unit survivors and nonsurvivors, respectively; P = 0.753). Correlation between Standard Base Deficit and lactate was found only in Intensive Care Unit nonsurvivors (r = 0.662, P < 0.01). DISCUSSION Hyperlactatemia is usually accompanied by metabolic acidemia, but lactate is responsible for a minor percentage of the acidosis; unmeasured anions account for most of the acidosis in patients with hyperlactatemia. The percentage of the acidosis due to hyperlactatemia was not relevant in terms of outcome.
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Affiliation(s)
- Alexandre Toledo Maciel
- Department of Medical Emergencies, São Paulo University Medical School, São Paulo, SP, Brazil.
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Rivers E. The outcome of patients presenting to the emergency department with severe sepsis or septic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2006; 10:154. [PMID: 16887012 PMCID: PMC1750981 DOI: 10.1186/cc4973] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Although multiple studies of acute myocardial infarction, trauma, and stroke have been translated into improved outcomes by applying diagnosis and therapy at the most proximal stage of hospital presentation (before intensive care unit arrival), this approach to the sepsis patient has been lacking. In response to this, a trial comparing early goal-directed therapy (EGDT) versus standard care was performed using internally and externally validated criteria for early identification of high risk patients, established definitions, and a consensus-derived protocol to reverse the hemodynamic perturbations of hypovolemia, vasoregulation, myocardial suppression and increased metabolic demands. That trial of EGDT resulted in significant reductions in morbidity, mortality, vasopressor use, and health care resource consumption. The end-points used in the protocol and the outcome results were subsequently externally validated, revealing similar or better mortality benefit. This commentary examines the rational and validation for the use of early markers of illness severity. Current evidence support the endpoints in the EGDT protocol, external validity in regards to outcome benefit and the universal need to improve the quality of care for early sepsis.
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Affiliation(s)
- Emanuel Rivers
- Emergency Medicine and Critical Care, Henry Ford Hospital, Detroit, Michigan, USA.
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Martin MJ, FitzSullivan E, Salim A, Brown CVR, 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. [PMID: 16647349 DOI: 10.1016/j.amjsurg.2006.02.014] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2005] [Revised: 01/17/2006] [Indexed: 11/16/2022]
Abstract
PURPOSE Both lactate and base deficit (BD) are used as predictors of injury severity and mortality. We examined the significance of these measures when used in combination, and particularly when they provide conflicting data. METHODS We reviewed all intensive care unit patients with simultaneously obtained lactate and BD measurements. The ability to predict mortality and hospital stay was compared alone, in combination, and when there was disagreement between the measures. Receiver operating characteristic curves were generated to compare predictive abilities. RESULTS There were 1,298 patients with 12,197 sets of paired laboratory data; 1,026 trauma patients and 272 surgical patients. Lactic acidosis was present in 41% and a significant BD level (> 2) was found in 52%. Nonsurvivors had higher admission lactate (6.2 vs. 3.3) and base deficit (6.1 vs. 3.2) levels than survivors (both P < .01), with a modest correlation (r = .52) between the measures. The admission lactate and BD levels had similar predictive ability for mortality, with areas under the receiver operating characteristic curve of .7 and .66, respectively (both P < .01). However, the predictive ability of the BD level decreased significantly during the intensive care unit stay (area, .5) compared with lactate level (area, .68). Lactate and BD levels disagreed in 44% of all laboratory sets. In patients with a normal lactate level (< 2.2), the BD level had no predictive ability for mortality (area, .48; P = .26). However, in patients with a normal BD level (< 2.0), the lactate level retained its predictive ability for mortality (area, .67; P < .01). Lengths of stay were longer among patients with an increased lactate level, even when the BD level was normal. There was no improvement in predictive ability using a combination of the 2 measures. CONCLUSIONS Both lactate and BD levels may be used to identify lactic acidosis and predict mortality at admission. Increased lactate levels predict mortality and a prolonged course regardless of the associated BD level, whereas an increased BD level has no predictive value if the lactate level is normal.
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Affiliation(s)
- Matthew J Martin
- Division of Trauma and Surgical Critical Care, Keck School of Medicine, University of Southern California and the Los Angeles County and University of Southern California Medical Center, Los Angeles, CA, USA.
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Jauchem JR, Sherry CJ, Fines DA, Cook MC. Acidosis, lactate, electrolytes, muscle enzymes, and other factors in the blood of Sus scrofa following repeated TASER exposures. Forensic Sci Int 2005; 161:20-30. [PMID: 16289999 DOI: 10.1016/j.forsciint.2005.10.014] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2005] [Revised: 10/05/2005] [Accepted: 10/18/2005] [Indexed: 11/25/2022]
Abstract
Repeated exposure to electro-muscular incapacitating devices could result in repetitive, sustained muscle contraction, with little or no muscle recovery period. Therefore, rhabdomyolysis and other physiological responses, including acidosis, hyperkalaemia, and altered levels of muscle enzymes in the blood, would be likely to occur. Experiments were performed to investigate effects of repeated exposures of TASER International's Advanced TASER X26 on muscle contraction and resultant changes in blood factors in an anaesthetized swine model. A total of 10 animals were used. Six swine were exposed for 5 s, followed by a 5-s period of no exposure, repeatedly for 3 min. (In five of the animals, after a 1-h delay, a second 3-min exposure period was added.) The remaining four animals were used for an additional pilot study. All four limbs of each animal exhibited contraction even though the electrodes were positioned in areas at some distances from the limbs. The degree of muscle contraction generated during the second exposure period was significantly lower than that in the first exposure series. This finding was consistent with previous studies showing that prolonged activity in skeletal muscle will eventually result in a decline of force production. There were some similarities in blood sample changes in the current experiments with previous studies of muscular exercise. Thus problems concerning biological effects of repeated TASER exposures may be related, not directly to the "electric output" per se, but rather to the resulting contraction of muscles (and related interruption of respiration) and subsequent sequelae. Transient increases in hematocrit, potassium, and sodium were consistent with previous reports in the literature dealing with studies of muscle stimulation or exercise. It is doubtful that these short-term elevations would have any serious health consequences in a healthy individual. Blood pH was significantly decreased for 1h following exposure, but subsequently returned toward a normal level. Leg muscle contractions and decreases in respiration each appeared to contribute to the acidosis. Lactate was highly elevated, with a slow return (time course greater than 1 h) to baseline. Other investigators have reported profound metabolic acidosis during restraint-associated cardiac arrest. Since restraint often occurs immediately after TASER exposure, this issue should be considered in further development of deployment concepts. On the basis of the results of the current studies, the repeated use of electro-muscular incapacitating devices in a short period of time is, at least, feasible, with the caveat that some medical monitoring of subjects may be required (to observe factors such as lactate and acidosis).
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Affiliation(s)
- James R Jauchem
- Air Force Research Laboratory, Human Effectiveness Directorate, Directed Energy Bioeffects Division, Brooks City-Base, Texas 78235, USA.
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18
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Jackson DC. Surviving extreme lactic acidosis: the role of calcium lactate formation in the anoxic turtle. Respir Physiol Neurobiol 2004; 144:173-8. [PMID: 15556100 DOI: 10.1016/j.resp.2004.06.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2004] [Indexed: 10/26/2022]
Abstract
During prolonged anoxia at low temperature, freshwater turtles develop high plasma concentrations of both lactate and calcium. At these concentrations the formation of the complex, calcium lactate, normally of little biological significance because of the low association constant for the reaction, significantly reduces the free concentrations of both lactate and calcium. In addition, lactate is taken up by the shell and skeleton to an extent that strongly indicates that calcium lactate formation participates in these structures as well. The binding of calcium to lactate thus contributes to the efflux of lactic acid from the anoxic cells and to the exploitation of the powerful buffering capacity of the shell and skeleton.
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Affiliation(s)
- Donald C Jackson
- Department of Molecular Pharmacology, Physiology and Biotechnology, Brown University, Providence, RI 02912, USA.
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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. [PMID: 12727572 DOI: 10.1016/s0002-9610(03)00044-8] [Citation(s) in RCA: 299] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To determine whether lactate levels and base deficits in critically ill surgical intensive care unit (SICU) patients correlate and whether either measure is a significant indicator of mortality and morbidity. METHODS A review was made of 137 SICU patients who had serial lactate and blood gas measurements. Patients were stratified by absolute lactate and base deficit values as well as time to lactate clearance. RESULTS Initial and 24-hour lactate level was significantly elevated in nonsurvivors versus survivors (P = 0.002). Initial base deficit was not significantly different; 24-hour base deficit did achieve statistical significance (P = 0.02). Subgroup analysis among trauma patients (n = 36) and major abdominal surgery (n = 101) confirmed the significant correlation between lactate levels and survival. There was poor correlation between initial and 24-hour lactate and base deficit among all patients (r = -0.3 and -0.5). Mortality if lactate normalized within 24 hours was 10%, compared with 24% for >48 hours and 67% if lactate failed to normalize. Physical status at discharge was related to initial lactate (P = 0.05), as well as to lactate clearance time (P = 0.01). CONCLUSIONS Elevated initial and 24-hour lactate levels are significantly correlated with mortality and appear to be superior to corresponding base deficit levels. Lactate clearance time may be used to predict mortality and is associated with outcome at discharge. Initial base deficit is a poor predictor of mortality and did not correlate with lactate levels except in trauma nonsurvivors. In addition to being used as an endpoint for resuscitation, lactate may be predictive of certain morbidities and patient outcome at discharge.
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Affiliation(s)
- Farah A Husain
- Department of Surgery, Madigan Army Medical Center, Fort Lewis, WA 98431, USA.
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20
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Powner DJ, Kellum JA, Darby JM. Concepts of the Strong Ion Difference Applied to Large Volume Resuscitation. J Intensive Care Med 2001. [DOI: 10.1046/j.1525-1489.2001.00169.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Hypocalcemia is common in the ICU and is a marker of poor prognosis. The mechanisms behind the low calcium levels include extravasation, increased chelation, intracellular overload of calcium, and an altered parathyroid hormone (PTH) secretion. Hypocalcemia and an altered PTH secretion seem to be related to systemic inflammation, but it is not known today if this response is appropriate or not. Therefore, a general supplementation with calcium in these patients cannot be recommended at this stage.
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Affiliation(s)
- F Carlstedt
- Department of Medical Science, Uppsala University, Uppsala, Sweden.
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22
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Charpie JR, Dekeon MK, Goldberg CS, Mosca RS, Bove EL, Kulik TJ. Serial blood lactate measurements predict early outcome after neonatal repair or palliation for complex congenital heart disease. J Thorac Cardiovasc Surg 2000; 120:73-80. [PMID: 10884658 DOI: 10.1067/mtc.2000.106838] [Citation(s) in RCA: 144] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Neonates with congenital heart disease may appear hemodynamically stable after operation and then suddenly experience catastrophic decompensation. An improved means of predicting which infants will suddenly die in the early postoperative period may lead to lifesaving interventions. Studies indicate that blood lactate level is proportional to tissue oxygen debt, but information linking lactate levels with outcome in infants after operation is limited. We sought to determine whether a change in lactate level over time was predictive of a poor outcome defined as death within the first 72 hours or the need for extracorporeal membrane oxygenation. METHODS To test this hypothesis, we studied prospectively 46 infants who were less than 1 month old and were undergoing complex cardiac surgical palliation or repair. Postoperative arterial oxygen saturation, bicarbonate, and lactate levels were recorded on admission to the intensive care unit and every 3 to 12 hours for the first 3 days. RESULTS Thirty-seven patients had a good outcome, and 9 patients had a poor outcome. Mean initial lactate level was significantly greater in patients with a poor outcome (9.4 +/- 3.8 mmol/L) than in patients with a good outcome (5.6 +/- 2.1 mmol/L; P =.03). However, an elevated initial lactate level of more than 6 mmol/L had a low positive predictive value (38%) for poor outcome. In contrast, a change in lactate level of 0.75 mmol/L per hour or more was associated with a poor outcome (P <.0001) and predicted a poor outcome with an 89% sensitivity value, a 100% specificity value, and a 100% positive predictive value. CONCLUSIONS Serial blood lactate level measurements may be an accurate predictor of death or the requirement for extracorporeal membrane oxygenator support for patients who undergo complex neonatal cardiac surgery.
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Affiliation(s)
- J R Charpie
- University of Michigan Congenital Heart Center, University of Michigan Medical Center, Ann Arbor, MI 48109-0204, USA.
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Cernak I, Savic VJ, Kotur J, Prokic V, Veljovic M, Grbovic D. Characterization of plasma magnesium concentration and oxidative stress following graded traumatic brain injury in humans. J Neurotrauma 2000; 17:53-68. [PMID: 10674758 DOI: 10.1089/neu.2000.17.53] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Plasma magnesium, calcium, and oxidative status were investigated in 31 male casualties with traumatic brain injury (TBI) during a 7-day posttraumatic period. The study group consisted of eight patients with mild closed head injury (Glasgow Coma Scale score [GCS] of 13-15), 10 patients with extensive penetrating head injury (GCS 4-6), and 13 patients with blast injuries but without direct head trauma. The latter group was included since previous experimental and clinical data have confirmed the development of indirect brain trauma in patients with blast injuries. Patients with multiple injuries were not included. Significant declines in plasma divalent cations were found in GCS 4-6 patients immediately after TBI and persisting for the entire 7-day study period. Similar changes in magnesium, but not calcium, were present in the GCS 13-15 and the blast injury groups, but only up until day 3 after injury. Alterations in lipid peroxidation products and superoxide anions were also observed following TBI. Increased lipid peroxidation was noted in all three groups over the entire posttraumatic period while increases in superoxide anion generation occurred transiently immediately following TBI. Thereafter, in the GCS 13-15 and blast injury groups, superoxide anions subsequently normalized, whereas in extensive head injury (GCS 4-6), superoxide anion generation significantly declined. A negative correlation between magnesium balance and oxidative stress was observed in all patients immediately after injury persisting in GCS 4-6 patients to the end of the observation period. Our findings suggest an interrelationship between magnesium changes and blood oxidants/antioxidants after TBI, which could be of both diagnostic and prognostic value in patients with neurotrauma.
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Affiliation(s)
- I Cernak
- Military Medical Academy, Belgrade, Yugoslavia.
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Walsh TS, McLellan S, Mackenzie SJ, Lee A. Hyperlactatemia and pulmonary lactate production in patients with fulminant hepatic failure. Chest 1999; 116:471-6. [PMID: 10453878 DOI: 10.1378/chest.116.2.471] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To determine whether the lungs of patients with fulminant hepatic failure release lactate, and if so, whether this release relates to systemic lactate concentration or acid base status. Another objective was to examine the accuracy of lactate flux calculations in critically ill patients. DESIGN Prospective observational study. SETTING The ICU of a major teaching hospital. PATIENTS Twelve patients with fulminant hepatic failure; 30 other critically ill patients in whom a pulmonary artery catheter was in place. INTERVENTIONS None. MEASUREMENT AND RESULTS The precision of whole-blood lactate measurements was assessed in 30 patients with critical illnesses of variable etiology who had a wide range of arterial lactate concentrations. The reliability of lactate measurements decreased with increasing lactate concentration. In each patient with liver failure, pulmonary lactate flux was calculated on three occasions using the Fick principle. Arterial blood lactate concentration was consistently higher than venous concentrations, indicating lactate release by the lungs (mean difference, 0.15 mmol/L; 95% confidence interval, 0.09 to 0.21; p<0.001). Mean pulmonary lactate production for the 12 patients was 83 mmol/h (range, 22 to 210 mmol/h). No patient had significant acute lung injury. Correlations were found among the arterial lactate concentration and both the arteriovenous (AV) lactate difference (p<0.025) and pulmonary lactate production (p<0.05), but not with acid-base status or cardiac output. The reliability of individual AV lactate difference calculations and pulmonary lactate flux calculations was poor. CONCLUSION The lungs release lactate in patients with fulminant hepatic failure at a rate proportional to the degree of systemic hyperlactatemia. However, the measurement errors associated with pulmonary lactate flux calculations using the Fick principle are large, so individual measurements should be interpreted with caution.
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Affiliation(s)
- T S Walsh
- Department of Anaesthetics, Royal Infirmary, Edinburgh, Scotland
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Poli de Figueiredo LF, Malbouisson LM, Varicoda EY, Carmona MJ, Auler JO, Rocha e Silva M. Thermal filament continuous thermodilution cardiac output delayed response limits its value during acute hemodynamic instability. THE JOURNAL OF TRAUMA 1999; 47:288-93. [PMID: 10452463 DOI: 10.1097/00005373-199908000-00011] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND It has been suggested that measurement of continuous cardiac output (CCO) is an advancement in the management of critically ill patients. Our objective was to determine the accuracy of CCO during the rapid hemodynamic changes induced by hemorrhage and resuscitation. METHODS In 12 anesthetized dogs (20.2+/-0.9 kg), pulmonary artery blood flow, our "gold standard" cardiac output, was measured with an sonographic flowprobe, whereas CCO, intermittent bolus cardiac output (ICO), and mixed venous oxygen saturation were measured with a thermodilution fiberoptic pulmonary artery catheter with a thermal filament. A graded hemorrhage (20 mL/min) was produced to a mean arterial pressure of 40 mm Hg, which was maintained at this level for 30 minutes. Total shed blood volume (701+/-53 mL) was retransfused at a rate of 40 mL/min, over 30 minutes, after which a massive hemorrhage (100 mL/min) was produced over 10 minutes. RESULTS Hemorrhage induced significant decreases in mean arterial pressure, mixed venous oxygen saturation, and oxygen delivery, which were all restored during early resuscitation. However, CCO showed a delayed response after hemorrhage and resuscitation, compared with pulmonary blood flow, throughout the study (r = 0.549), matching only at baseline and at the end of both graded hemorrhage and resuscitation periods. There was a good correlation between ICO and pulmonary artery blood flow (r = 0.964) and no significant differences between them throughout the study. CONCLUSION CCO has a delayed response during acute hemodynamic changes induced by hemorrhage and resuscitation. When sudden changes in mean arterial pressure or in mixed venous oxygen saturation are detected, cardiac output must be estimated by the standard bolus thermodilution technique, not by CCO.
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Balasubramanyan N, Havens PL, Hoffman GM. Unmeasured anions identified by the Fencl-Stewart method predict mortality better than base excess, anion gap, and lactate in patients in the pediatric intensive care unit. Crit Care Med 1999; 27:1577-81. [PMID: 10470767 DOI: 10.1097/00003246-199908000-00030] [Citation(s) in RCA: 168] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES This study was undertaken to compare three methods for the identification of unmeasured anions in pediatric patients with critical illness. We compared the base excess (BE) and anion gap (AG) methods with the less commonly used Fencl-Stewart strong ion method of calculating BE caused by unmeasured anions (BEua). We measured the relationship of unmeasured anions identified by the three methods to serum lactate concentrations and to mortality. DESIGN Retrospective cohort study. SETTING Tertiary care pediatric intensive care unit in an academic pediatric hospital. PATIENTS The study population included 255 patients in the pediatric intensive care unit who had simultaneous measurements of arterial blood gases, electrolytes, and albumin during the period of July 1995 to December 1996. Sixty-six of the 255 patients had a simultaneous measurement of serum lactate. MEASUREMENTS AND MAIN RESULTS The BEua was calculated using the Fencl-Stewart method. The AG was defined as (sodium plus potassium) - (chloride plus total carbon dioxide). BE was calculated from the standard bicarbonate, which is derived from the Henderson-Hasselbalch equation and reported on the blood gas analysis. A BE or BEua value of < or =-5 mEq/L or an AG > or =17 mEq/L was defined as a clinically significant presence of unmeasured anions. A lactate level of > or =45 mg/dL was defined as being abnormally elevated for this study. The presence of unmeasured anions identified by significantly abnormal BEua was poorly identified by BE or AG. Of the 255 patients included in the study, 67 (26%) had a different interpretation of acid base balance when the Fencl method was used compared with when BE and AG were used. Plasma lactate concentration correlated better with BEua (r2 = .55; p = .0001) than with AG (r2 = .41; p = .0005) or BE (r2 = .27; p = .025). Mortality was more strongly related to BEua < or =-5 mEq/L (relative risk of death = 10.25; p = .002) than to lactate > or =45 mg/dL (relative risk of death = 2.35; p = .04). In logistic regression analysis, mortality was more strongly associated with BEua (area under the receiver operating characteristic curve = 0.79; p = .0002) than lactate (receiver operating characteristic curve area = 0.63; p = .05), BE (receiver operating characteristic curve area = 0.53; p = .32), or AG (receiver operating characteristic curve area = 0.64; p = .08) in this patient sample. CONCLUSIONS Critically ill patients with normal BE and normal AG frequently have elevated unmeasured anions detectable by BEua. The Fencl-Stewart method is better than BE and similar to AG in identifying patients with high lactate levels. Elevated unmeasured anions identified by the Fencl-Stewart method were more strongly associated with mortality than with BE, AG, or lactate in this patient sample.
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Affiliation(s)
- N Balasubramanyan
- Department of Pediatrics, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, USA
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Deshpande SA, Platt MP. Association between blood lactate and acid-base status and mortality in ventilated babies. Arch Dis Child Fetal Neonatal Ed 1997; 76:F15-20. [PMID: 9059180 PMCID: PMC1720617 DOI: 10.1136/fn.76.1.f15] [Citation(s) in RCA: 121] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
AIM To investigate the relation between common acid-base parameters and blood lactate concentrations and their prognostic importance in sick, ventilated neonates. METHODS Two hundred and seventy eight serial simultaneous measurements of arterial acid-base status and blood lactate concentrations were carried out in 75 mechanically ventilated neonates with indwelling arterial catheters (gestational age and birthweight, median (range) -29 (23-40) weeks, and 1340 (550-4080) g, respectively). RESULTS There were no correlations between arterial blood lactate and pH and base excess within subjects (r = 0.07 and r = -0.06, respectively) and only weakly positive but clinically irrelevant positive correlations between subjects (r = 0.28 and r = 0.27) in this group. Even in those infants who had not received any bicarbonate before their initial measurements (n = 48), there were no correlations between initial blood lactate concentrations and pH (r = 0.27), base excess (r = 0.17), or serum bicarbonate concentrations (r = -0.18). There was no relation between peak lactate concentration (PLC) and base excess (r = 0.16), and only a weak correlation between peak lactate concentration (PLC) and pH (r = 0.28). Negative base excess was an insensitive indicator of raised lactate concentrations. Only two out of 33 (6%) instances of hyperlactataemia (lactate > 2.5 mmol/l) would have been identified with a base excess < -10 mmol/l as a cutoff. Lower cutoff values of base excess or pH performed no better. Raised lactate concentrations were associated with increased mortality at all levels. While six of 53 (11%) infants with a PLC < 2.5 mmol/l died, this proportion increased to four of 15 (27%) with a PLC between 2.5-5.0 mmol/l, and four of seven (57%) with a PLC > 5.0 mmol/l. Infants showing little rise or a substantial fall in blood lactate fared better than those with persistently raised values. A clinically important increase in blood lactate preceded the development of clinical markers of deterioration and complications in six infants. CONCLUSIONS Contrary to popular belief, pH or base excess cannot be used as proxy measures for blood lactate concentration, and independent measurement of the latter are needed. Blood lactate concentrations may provide an early warning signal and important prognostic information in ill, ventilated neonates. In this regard, serial measurements of blood lactate are more useful than a single value.
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Affiliation(s)
- S A Deshpande
- Newcastle Neonatal Service, Special Care Baby Unit, Royal Victoria Infirmary, Newcastle upon Tyne
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Lagutchik MS, Ogilvie GK, Wingfield WE, Hackett TB. Lactate Kinetics in veterinary Critical Care: A Review. J Vet Emerg Crit Care (San Antonio) 1996. [DOI: 10.1111/j.1476-4431.1996.tb00036.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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