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Allo G, Gülcicegi D, Gillessen J, Kasper P, Chon SH, Goeser T, Bürger M. Timing of endoscopy in patients with elevated lactate levels and acute upper gastrointestinal bleeding; a retrospective comparative study. Scand J Gastroenterol 2024; 59:512-517. [PMID: 38149333 DOI: 10.1080/00365521.2023.2298355] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/18/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND/AIMS While current guidelines recommend performing endoscopy within 24 h in case of acute upper gastrointestinal bleeding (AUGIB), the precise timing remains an issue of debate. Lactate is an established parameter for risk stratification in a variety of medical emergencies. This study evaluated the predictive ability of elevated lactate levels in identifying patients with UGIB, who may benefit from emergent endoscopy. METHODS We retrospectively analyzed all patients with elevated lactate levels, who presented to our emergency department between 01 January 2015 and 31 December 2019 due to suspected AUGIB. RESULTS Of 134 included cases, 81.3% had an Charlson comorbidity index of ≥3 and 50.4% presented with shock. Fifteen (11.2%) patients died and mortality rates rose with increasing lactate levels. Emergent endoscopy within 6 h (EE) and non-EE were performed in 64 (47.8%) and 70 (52.2%) patients, respectively. Patients who underwent EE had lower systolic blood pressure (107.6 mmHg vs. 123.2 mmHg; p = 0.001) and received blood transfusions more frequently (79.7% vs 64.3%; p = 0.048), but interestingly need for endoscopic intervention (26.6% vs 20.0%; p = 0.37), rebleeding (17.2% vs. 15.7%; p = 0.82) and mortality (9.4% vs. 11.4%; p = 0.7) did not differ significantly. CONCLUSION In conclusion, our findings support the recommendations of current guidelines to perform non-EE after sufficient resuscitation and management of comorbid illnesses.
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Affiliation(s)
- Gabriel Allo
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Dilan Gülcicegi
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Johannes Gillessen
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Philipp Kasper
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Seung-Hun Chon
- Department of General, Visceral and Cancer and Transplant Surgery, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Tobias Goeser
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Martin Bürger
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
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2
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Schauer SG, April MD, Fisher AD, Weymouth WL, Maddry JK, Gillespie KR, Salinas J, Cap AP. Hypothermia in the Combat Trauma Population. PREHOSP EMERG CARE 2022; 27:934-940. [PMID: 36037100 DOI: 10.1080/10903127.2022.2119315] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/29/2022] [Accepted: 08/25/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND The MARCH (Massive hemorrhage, Airway, Respirations, Circulation, and Hypothermia/Head injuries) algorithm taught to military medics includes interventions to prevent hypothermia. As possible sequelae from major trauma, hypothermia is associated with coagulopathy and lower survival. This paper sought to define hypothermia within our combat trauma population using an outcomes-based method, and determine clinical variables associated with hypothermia. METHODS This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry focused on casualties who received prehospital care. A receiver operating curve was constructed and Youden's index was used to define hypothermia within the predetermined population based on mortality risk. A multivariable regression model was used to identify associations. RESULTS There were 23,243 encounters that met the inclusion criteria for this study with patients having received prehospital care and documentation of at least one emergency department temperature. An optimal threshold of 36.2° C was found to predict mortality; 3,159 casualties had temperatures below this threshold (14%). Survival to discharge was lower among casualties with hypothermia (91% versus 98%). Hypothermic casualties were less likely to undergo blanket application (38% versus 40%). However, they had higher proportions with Hypothermia Prevention and Management Kit application (11% versus 7%) and radiant warming (2% versus 1%). On multivariable regression modeling, none of the hypothermia interventions were associated with a decreased likelihood of hypothermia. Non-hypothermia interventions associated with hypothermia included prehospital intubation (OR 1.57, 95% CI 1.45-1.69) and blood product administration. CONCLUSIONS Hypothermia, including a single recorded low temperature in the patient care record, was associated with worse outcomes in this combat trauma population. Prehospital intubation was most strongly associated with developing hypothermia. Prehospital warming interventions were not associated with a reduction in hypothermia risk. Our dataset suggests that current methods for prehospital warming are inadequate.
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Affiliation(s)
- Steven G Schauer
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- 40th Forward Resuscitation and Surgical Detachment, Fort Carson, Colorado, USA
| | - Andrew D Fisher
- University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
- Texas Army National Guard, Austin, Texas, USA
| | - Wells L Weymouth
- 160th Special Operations Aviation Regiment, Hunter Army Airfield, Georgia, USA
| | - Joseph K Maddry
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- 59th Medical Wing, JBSA Fort Sam Houston, Texas, USA
| | - Kevin R Gillespie
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - Jose Salinas
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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3
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Farnesysltransferase Inhibitor Prevents Burn Injury-Induced Metabolome Changes in Muscle. Metabolites 2022; 12:metabo12090800. [PMID: 36144205 PMCID: PMC9506277 DOI: 10.3390/metabo12090800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/06/2022] [Accepted: 08/22/2022] [Indexed: 01/01/2023] Open
Abstract
Burn injury remains a significant public health issue worldwide. Metabolic derangements are a major complication of burn injury and negatively affect the clinical outcomes of severely burned patients. These metabolic aberrations include muscle wasting, hypermetabolism, hyperglycemia, hyperlactatemia, insulin resistance, and mitochondrial dysfunction. However, little is known about the impact of burn injury on the metabolome profile in skeletal muscle. We have previously shown that farnesyltransferase inhibitor (FTI) reverses burn injury-induced insulin resistance, mitochondrial dysfunction, and the Warburg effect in mouse skeletal muscle. To evaluate metabolome composition, targeted quantitative analysis was performed using capillary electrophoresis mass spectrometry in mouse skeletal muscle. Principal component analysis (PCA), partial least squares discriminant analysis (PLS-DA), and hierarchical cluster analysis demonstrated that burn injury induced a global change in metabolome composition. FTI treatment almost completely prevented burn injury-induced alterations in metabolite levels. Pathway analysis revealed that the pathways most affected by burn injury were purine, glutathione, β-alanine, glycine, serine, and threonine metabolism. Burn injury induced a suppressed oxidized to reduced nicotinamide adenine dinucleotide (NAD+/NADH) ratio as well as oxidative stress and adenosine triphosphate (ATP) depletion, all of which were reversed by FTI. Moreover, our data raise the possibility that burn injury may lead to increased glutaminolysis and reductive carboxylation in mouse skeletal muscle.
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Thota V, Paravathaneni M, Konduru S, Buragamadagu BC, Thota M, Lerman G. Treatment of Refractory Lactic Acidosis With Thiamine Administration in a Non-alcoholic Patient. Cureus 2021; 13:e16267. [PMID: 34373820 PMCID: PMC8346261 DOI: 10.7759/cureus.16267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 11/05/2022] Open
Abstract
Lactate, or lactic acid, is an end-product of anaerobic metabolism. The build-up of lactate in the body is commonly due to type A lactic acidosis, resulting from an inability to meet the body's oxygen delivery demands. When lactic acidosis persists, other causes need to be ruled out. Here, we describe the case of a 63-year-old female who initially presented with hypoglycemia and was found to have significant lactic acidosis. Her blood sugar levels improved with dextrose supplementation; however, lactic acidosis persisted despite fluid hydration and empiric antibiotics. After excluding other causes of lactic acidosis, she was started on intravenous thiamine due to suspicion of thiamine deficiency secondary to poor nutrition. Lactic acid levels improved drastically after starting thiamine supplementation. Thiamine is a water-soluble vitamin that plays an essential role as a cofactor in several biochemical reactions. Thiamine deficiency is a rare, underdiagnosed cause of type B lactic acidosis, with early diagnosis and intervention playing crucial roles in preventing severe cardiac and neurological impairment.
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Affiliation(s)
- Vihitha Thota
- Internal Medicine, Mercy Catholic Medical Center, Darby, USA
| | | | - Sudheer Konduru
- Internal Medicine, Mercy Catholic Medical Center, Darby, USA
| | | | - Manaswitha Thota
- Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, USA
| | - Gabriel Lerman
- Critical Care, Mercy Catholic Medical Center, Darby, USA
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D'Abrantes R, Dunn L, McMillan T, Cornwell B, Bloom B, Harris T. Evaluation of the Prognostic Value of Lactate and Acid-Base Status in Patients Presenting to the Emergency Department. Cureus 2021; 13:e15857. [PMID: 34327084 PMCID: PMC8301278 DOI: 10.7759/cureus.15857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/23/2021] [Indexed: 11/23/2022] Open
Abstract
Background Lactate levels predict mortality in a wide range of patients presenting to the Emergency Department (ED); however, the effect of co-existing acidosis is unknown. Here, we investigated the effect of acidosis on in-hospital mortality for patients with hyperlactataemia. Methodology This is a retrospective cohort study of adults cared for in the resuscitation area of one ED who received a metabolic panel on arrival. The primary outcome was in-hospital mortality for patients with normal lactate (0.0-2.0 mmol/L), intermediate lactate (2.1-4.0 mmol/L), or high lactate (>4.0 mmol/L), with and without acidosis. Odds ratios (ORs) were calculated to assess the differences in mortality rates between groups stratified by lactate and acid-base status. Results A total of 4,107 metabolic panels were collected and 3,238 were assessed. In total, 510 (15.8%) and 784 (24.2%) patients had a normal lactate and acidosis/no acidosis; 587 (18.1%) and 842 (26.0%) had intermediate lactate and acidosis/no acidosis; and 388 (12.0%) and 127 (3.9%) had high lactate and acidosis/no acidosis, respectively. The overall mortality was 5%. Mortality was 4.3%/0.6% in the normal lactate, 5.6%/2.6% in the intermediate lactate, and 19.3%/3.9% in the high lactate groups, with and without acidosis, respectively. Combining base excess <-6 and lactate >4 mmol/L had a sensitivity of 39%, specificity of 96%, positive predictive value of 32%, and negative predictive value of 98% for in-hospital mortality (OR: 14.0; 95% confidence interval: 9.77-20.11). Conclusions In an undifferentiated cohort of ED patients presenting to the resuscitation area lactaemia associated with acidosis is a more accurate predictor of in-hospital mortality than hyperlactataemia.
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Affiliation(s)
| | - Laura Dunn
- Emergency Medicine, Barts Health NHS Trust, London, GBR
| | - Tim McMillan
- Emergency Medicine, Barts Health NHS Trust, London, GBR
| | | | - Ben Bloom
- Emergency Medicine, Barts Health NHS Trust, London, GBR.,Emergency Medicine, Queen Mary University of London, London, GBR
| | - Tim Harris
- Emergency Medicine, Queen Mary University of London, London, GBR.,Emergency Medicine, Barts Health NHS Trust, London, GBR
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Seichter F, Vogt J, Tütüncü E, Hagemann LT, Wachter U, Gröger M, Kress S, Radermacher P, Mizaikoff B. Metabolic monitoring via on-line analysis of 13C-enriched carbon dioxide in exhaled mouse breath using substrate-integrated hollow waveguide infrared spectroscopy and luminescence sensing combined with Bayesian sampling. J Breath Res 2021; 15:026013. [PMID: 33630755 DOI: 10.1088/1752-7163/ab8dcd] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
In studies that target specific functions or organs, the response is often overlaid by indirect effects of the intervention on global metabolism. The metabolic side of these interactions can be assessed based on total energy expenditure (TEE) and the contributions of the principal energy sources, carbohydrates, proteins and fat to whole body CO2 production. These parameters can be identified from indirect calorimetry using respiratory oxygen intake and CO2 dioxide production data that are combined with the response of the 13CO2 release in the expired air and the glucose tracer enrichment in plasma following a 13C glucose stable isotope infusion. This concept is applied to a mouse protocol involving anesthesia, mechanical respiration, a disease model, like hemorrhage and therapeutic intervention. It faces challenges caused by a small sample size for both breath and plasma as well as changes in metabolic parameters caused by disease and intervention. Key parameters are derived from multiple measurements, all afflicted with errors that may accumulate leading to unrealistic values. To cope with these challenges, a sensitive on-line breath analysis system based on substrate-integrated hollow waveguide infrared spectroscopy and luminescence (iHWG-IR-LS) was used to monitor gas exchange values. A Bayesian statistical model is developed that uses established equations for indirect calorimetry to predict values for respiratory gas exchange and tracer data that are consistent with the corresponding measurements and also provides statistical error bands for these parameters. With this new methodology, it was possible to estimate important metabolic parameters (respiratory quotient (RQ), relative contribution of carbohydrate, protein and fat oxidation fcarb, ffat and fprot , total energy expenditure TEE) in a resolution never available before for a minimal invasive protocol of mice under anesthesia.
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Affiliation(s)
- Felicia Seichter
- Institute of Analytical and Bioanalytical Chemistry, Ulm University, Albert-Einstein-Allee 11, 89081, Ulm, Germany
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7
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Küchler J, Klaus S, Bahlmann L, Onken N, Keck A, Smith E, Gliemroth J, Ditz C. Cerebral effects of resuscitation with either epinephrine or vasopressin in an animal model of hemorrhagic shock. Eur J Trauma Emerg Surg 2020; 46:1451-1461. [PMID: 31127320 DOI: 10.1007/s00068-019-01158-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 05/20/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE The use of epinephrine (EN) or vasopressin (VP) in hemorrhagic shock is well established. Due to its specific neurovascular effects, VP might be superior in concern to brain tissue integrity. The aim of this study was to evaluate cerebral effects of either EN or VP resuscitation after hemorrhagic shock. METHODS After shock induction fourteen pigs were randomly assigned to two treatment groups. After 60 min of shock, resuscitation with either EN or VP was performed. Hemodynamics, arterial blood gases as well as cerebral perfusion pressure (CPP) and brain tissue oxygenation (PtiO2) were recorded. Interstitial lactate, pyruvate, glycerol and glutamate were assessed by cerebral and subcutaneous microdialysis. Treatment-related effects were compared using one-way ANOVA with post hoc Bonferroni adjustment (p < 0.05) for repeated measures. RESULTS Induction of hemorrhagic shock led to a significant (p < 0.05) decrease of mean arterial pressure (MAP), cardiac output (CO) and CPP. Administration of both VP and EN sufficiently restored MAP and CPP and maintained physiological PtiO2 levels. Brain tissue metabolism was not altered significantly during shock and subsequent treatment with VP or EN. Concerning the excess of glycerol and glutamate, we found a significant EN-related release in the subcutaneous tissue, while brain tissue values remained stable during EN treatment. VP treatment resulted in a non-significant increase of cerebral glycerol and glutamate. CONCLUSIONS Both vasopressors were effective in restoring hemodynamics and CPP and in maintaining brain oxygenation. With regards to the cerebral metabolism, we cannot support beneficial effects of VP in this model of hemorrhagic shock.
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Affiliation(s)
- Jan Küchler
- Department of Neurosurgery, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Stephan Klaus
- Department of Anesthesiology, Herz-Jesu-Krankenhaus Münster-Hiltrup, Münster, Germany
| | - Ludger Bahlmann
- Department of Anesthesiology, Klinikum Weser Egge, Höxter, Germany
| | - Nils Onken
- Department of Pediatrics, Klinikum Bremen-Mitte, Bremen, Germany
| | - Alexander Keck
- Department of Gynecology and Obstetrics, Klinikum Osnabrück, Osnabrück, Germany
| | - Emma Smith
- Department of Neurosurgery, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Jan Gliemroth
- Department of Neurosurgery, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Claudia Ditz
- Department of Neurosurgery, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
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Quantitative Assessment of Blood Lactate in Shock: Measure of Hypoxia or Beneficial Energy Source. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2608318. [PMID: 33150168 PMCID: PMC7603544 DOI: 10.1155/2020/2608318] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/18/2020] [Indexed: 12/16/2022]
Abstract
Blood lactate concentration predicts mortality in critically ill patients and is clinically used in the diagnosis, grading of severity, and monitoring response to therapy of septic shock. This paper summarizes available quantitative data to provide the first comprehensive description and critique of the accepted concepts of the physiology of lactate in health and shock, with particular emphasis on the controversy of whether lactate release is simply a manifestation of tissue hypoxia versus a purposeful transfer ("shuttle") of lactate between tissues. Basic issues discussed include (1) effect of nonproductive lactate-pyruvate exchange that artifactually enhances flux measurements obtained with labeled lactate, (2) heterogeneous tissue oxygen partial pressure (Krogh model) and potential for unrecognized hypoxia that exists in all tissues, and (3) pathophysiology that distinguishes septic from other forms of shock. Our analysis suggests that due to exchange artifacts, the turnover rate of lactate and the lactate clearance are only about 60% of the values of 1.05 mmol/min/70 kg and 1.5 L/min/70 kg, respectively, determined from the standard tracer kinetics. Lactate turnover reflects lactate release primarily from muscle, gut, adipose, and erythrocytes and uptake by the liver and kidney, primarily for the purpose of energy production (TCA cycle) while the remainder is used for gluconeogenesis (Cori cycle). The well-studied physiology of exercise-induced hyperlactatemia demonstrates massive release from the contracting muscle accompanied by an increased lactate clearance that may occur in recovering nonexercising muscle as well as the liver. The very limited data on lactate kinetics in shock patients suggests that hyperlactatemia reflects both decreased clearance and increased production, possibly primarily in the gut. Our analysis of available data in health and shock suggests that the conventional concept of tissue hypoxia can account for most blood lactate findings and there is no need to implicate a purposeful production of lactate for export to other organs.
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Rosenstein PG, Tennent-Brown BS, Hughes D. Clinical use of plasma lactate concentration. Part 1: Physiology, pathophysiology, and measurement. J Vet Emerg Crit Care (San Antonio) 2018. [PMID: 29533512 DOI: 10.1111/vec.12708] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To review the current literature with respect to the physiology, pathophysiology, and measurement of lactate. DATA SOURCES Data were sourced from veterinary and human clinical trials, retrospective studies, experimental studies, and review articles. Articles were retrieved without date restrictions and were sourced primarily via PubMed, Scopus, and CAB Abstracts as well as by manual selection. HUMAN AND VETERINARY DATA SYNTHESIS Lactate is an important energy storage molecule, the production of which preserves cellular energy production and mitigates the acidosis from ATP hydrolysis. Although the most common cause of hyperlactatemia is inadequate tissue oxygen delivery, hyperlactatemia can, and does occur in the face of apparently adequate oxygen supply. At a cellular level, the pathogenesis of hyperlactatemia varies widely depending on the underlying cause. Microcirculatory dysfunction, mitochondrial dysfunction, and epinephrine-mediated stimulation of Na+ -K+ -ATPase pumps are likely important contributors to hyperlactatemia in critically ill patients. Ultimately, hyperlactatemia is a marker of altered cellular bioenergetics. CONCLUSION The etiology of hyperlactatemia is complex and multifactorial. Understanding the relevant pathophysiology is helpful when characterizing hyperlactatemia in clinical patients.
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Affiliation(s)
- Patricia G Rosenstein
- Department of Veterinary Clinical Sciences, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Werribee, Victoria, Australia
| | - Brett S Tennent-Brown
- Department of Veterinary Clinical Sciences, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Werribee, Victoria, Australia
| | - Dez Hughes
- Department of Veterinary Clinical Sciences, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Werribee, Victoria, Australia
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Ferguson BS, Rogatzki MJ, Goodwin ML, Kane DA, Rightmire Z, Gladden LB. Lactate metabolism: historical context, prior misinterpretations, and current understanding. Eur J Appl Physiol 2018; 118:691-728. [PMID: 29322250 DOI: 10.1007/s00421-017-3795-6] [Citation(s) in RCA: 202] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 12/22/2017] [Indexed: 02/07/2023]
Abstract
Lactate (La-) has long been at the center of controversy in research, clinical, and athletic settings. Since its discovery in 1780, La- has often been erroneously viewed as simply a hypoxic waste product with multiple deleterious effects. Not until the 1980s, with the introduction of the cell-to-cell lactate shuttle did a paradigm shift in our understanding of the role of La- in metabolism begin. The evidence for La- as a major player in the coordination of whole-body metabolism has since grown rapidly. La- is a readily combusted fuel that is shuttled throughout the body, and it is a potent signal for angiogenesis irrespective of oxygen tension. Despite this, many fundamental discoveries about La- are still working their way into mainstream research, clinical care, and practice. The purpose of this review is to synthesize current understanding of La- metabolism via an appraisal of its robust experimental history, particularly in exercise physiology. That La- production increases during dysoxia is beyond debate, but this condition is the exception rather than the rule. Fluctuations in blood [La-] in health and disease are not typically due to low oxygen tension, a principle first demonstrated with exercise and now understood to varying degrees across disciplines. From its role in coordinating whole-body metabolism as a fuel to its role as a signaling molecule in tumors, the study of La- metabolism continues to expand and holds potential for multiple clinical applications. This review highlights La-'s central role in metabolism and amplifies our understanding of past research.
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Affiliation(s)
- Brian S Ferguson
- College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Matthew J Rogatzki
- Department of Health and Exercise Science, Appalachian State University, Boone, NC, USA
| | - Matthew L Goodwin
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA.,Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Daniel A Kane
- Department of Human Kinetics, St. Francis Xavier University, Antigonish, Canada
| | - Zachary Rightmire
- School of Kinesiology, Auburn University, 301 Wire Road, Auburn, AL, 36849, USA
| | - L Bruce Gladden
- School of Kinesiology, Auburn University, 301 Wire Road, Auburn, AL, 36849, USA.
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Burn-induced muscle metabolic derangements and mitochondrial dysfunction are associated with activation of HIF-1α and mTORC1: Role of protein farnesylation. Sci Rep 2017; 7:6618. [PMID: 28747716 PMCID: PMC5529411 DOI: 10.1038/s41598-017-07011-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 06/21/2017] [Indexed: 12/28/2022] Open
Abstract
Metabolic derangements are a clinically significant complication of major trauma (e.g., burn injury) and include various aspects of metabolism, such as insulin resistance, muscle wasting, mitochondrial dysfunction and hyperlactatemia. Nonetheless, the molecular pathogenesis and the relation between these diverse metabolic alterations are poorly understood. We have previously shown that burn increases farnesyltransferase (FTase) expression and protein farnesylation and that FTase inhibitor (FTI) prevents burn-induced hyperlactatemia, insulin resistance, and increased proteolysis in mouse skeletal muscle. In this study, we found that burn injury activated mTORC1 and hypoxia-inducible factor (HIF)-1α, which paralleled dysfunction, morphological alterations (i.e., enlargement, partial loss of cristae structure) and impairment of respiratory supercomplex assembly of the mitochondria, and ER stress. FTI reversed or ameliorated all of these alterations in burned mice. These findings indicate that these burn-induced changes, which encompass various aspects of metabolism, may be linked to one another and require protein farnesylation. Our results provide evidence of involvement of the mTORC1-HIF-1α pathway in burn-induced metabolic derangements. Our study identifies protein farnesylation as a potential hub of the signaling network affecting multiple aspects of metabolic alterations after burn injury and as a novel potential molecular target to improve the clinical outcome of severely burned patients.
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Vitin AA, Azamfirei L, Tomescu D, Lang JD. Perioperative Management of Lactic Acidosis in End-Stage Liver Disease Patient. ACTA ACUST UNITED AC 2017; 3:55-62. [PMID: 29967872 PMCID: PMC5769918 DOI: 10.1515/jccm-2017-0014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 04/28/2017] [Indexed: 12/13/2022]
Abstract
Lactic acidosis (LA) in end-stage liver disease (ESLD) patients has been recognized as one of the most complicated clinical problems and is associated with increased morbidity and mortality. Multiple-organ failure, associated with advanced stages of cirrhosis, exacerbates dysfunction of numerous parts of lactate metabolism cycle, which manifests as increased lactate production and impaired clearance, leading to severe LA-induced acidemia. These problems become especially prominent in ESLD patients, that undergo partial hepatectomy and, particularly, liver transplantation. Perioperative management of LA and associated severe acidemia is an inseparable part of anesthesia, post-operative and critical care for this category of patients, presenting a wide variety of challenges. In this review, lactic acidosis applied pathophysiology, clinical implications for ESLD patients, diagnosis, role of intraoperative factors, such as anesthesia and surgery-related, vasoactive agents impact, and also current treatment options and modalities have been discussed.
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Affiliation(s)
- Alexander A Vitin
- Department of Anesthesiology & Pain, Medicine University of Washington Medical Center, Seattle WA, USA
| | - Leonard Azamfirei
- University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
| | - Dana Tomescu
- "Carol Davila" University of Medicine and Pharmacy, Anesthesiology and Intensive Care Department 3, Fundeni Clinical Institute, Bucharest, Romania
| | - John D Lang
- Department of Anesthesiology & Pain, Medicine University of Washington Medical Center, Seattle WA, USA
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Kariya T, Ito N, Kitamura T, Yamada Y. Recovery from Extreme Hemodilution (Hemoglobin Level of 0.6 g/dL) in Cadaveric Liver Transplantation. ACTA ACUST UNITED AC 2015; 4:132-6. [PMID: 25974417 PMCID: PMC4548248 DOI: 10.1213/xaa.0000000000000132] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Decompensated hepatic failure occurred in a patient with a rare blood type. The patient had extreme hemodilution due to massive bleeding during liver transplantation. A shortage of matched and universal donor blood prompted us to transfuse albumin and fresh frozen plasma for intravascular volume resuscitation. The lowest hemoglobin was 0.6 g/dL, accompanied by ST depression and a serum lactate of 100 mg/dL. The accuracy of the measured value of 0.6 g/dL was confirmed. However, the patient recovered from this critical situation after transfusion, and he was eventually discharged from the hospital without significant sequelae. Maintaining normovolemia, administering pure oxygen, ensuring appropriate anesthetic depth, and maintaining minimal inotropic support were essential for this patient's survival during massive bleeding.
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Affiliation(s)
- Taro Kariya
- From the Departments of *Cardiovascular Medicine and †Anesthesia and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan; and ‡Department of Anesthesiology, Toho University Sakura Medical Center, Sakura, Chiba, Japan
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Hauffe T, Krüger B, Bettex D, Rudiger A. Shock Management for Cardio-surgical ICU Patients - The Golden Hours. Card Fail Rev 2015; 1:75-82. [PMID: 28785436 PMCID: PMC5490875 DOI: 10.15420/cfr.2015.1.2.75] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 09/22/2015] [Indexed: 12/14/2022] Open
Abstract
Postoperative shock following cardiac surgery is a serious condition with a high morbidity and mortality. There are four types of shock: cardiogenic, hypovolemic, obstructive and distributive and these can occur alone or in combination. Early identification of the underlying diseases and understanding of the mechanisms at play are key for successful management of shock. Prompt resuscitation measures are necessary to reverse the shock state and avoid permanent organ dysfunction or death. In this review, the authors focus on the management during the first 6 hours of shock (the 'golden hours'). They discuss how to optimise preload, vascular tone, contractility, heart rate and oxygen delivery. The review incorporates the findings of recent trials on early goal-directed therapy and includes practical recommendations in areas in which the evidence is scare or controversial. While the review focuses on cardio-surgical patients, the suggested treatment algorithms might be usefully expanded to other critically ill patients with shock arising from other causes.
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Affiliation(s)
- Till Hauffe
- Cardiosurgical Intensive Care Unit, Institute of Anaesthesiology, University Hospital Zurich,Zurich, Switzerland
| | - Bernard Krüger
- Cardiosurgical Intensive Care Unit, Institute of Anaesthesiology, University Hospital Zurich,Zurich, Switzerland
| | - Dominique Bettex
- Cardiosurgical Intensive Care Unit, Institute of Anaesthesiology, University Hospital Zurich,Zurich, Switzerland
| | - Alain Rudiger
- Cardiosurgical Intensive Care Unit, Institute of Anaesthesiology, University Hospital Zurich,Zurich, Switzerland
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Satoh E, Tagami T, Watanabe A, Matsumoto G, Suzuki G, Onda H, Fuse A, Gemma A, Yokota H. Association between serum lactate levels and early neurogenic pulmonary edema after nontraumatic subarachnoid hemorrhage. J NIPPON MED SCH 2015; 81:305-12. [PMID: 25391699 DOI: 10.1272/jnms.81.305] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE Few studies have described the risk factors associated with the development of neurological pulmonary edema (NPE) after subarachnoid hemorrhage (SAH). We have hypothesized that acute-phase increases in serum lactate levels are associated with the early development of NPE following SAH. The aim of this study was to clarify the association between lactic acidosis and NPE in patients with nontraumatic SAH. METHODS We retrospectively evaluated 140 patients with nontraumatic SAH who were directly transported to the Nippon Medical School Hospital emergency room by the emergency medical services. We compared patients in whom NPE developed (NPE group) and those in whom it did not (non-NPE group). RESULTS The median (quartiles 1-3) arrival time at the hospital was 32 minutes (28-38 minutes) after the emergency call was received. Although the characteristics of the NPE and non-NPE groups, including mean arterial pressure (121.3 [109.0-144.5] and 124.6 [108.7-142.6] mm Hg, respectively; P=0.96), were similar, the median pH and the bicarbonate ion (HCO3(-)) concentrations were significantly lower in the NPE group than in the non-NPE group (pH, 7.33 [7.28-7.37] vs. 7.39 [7.35-7.43]); P=0.002; HCO3(-), 20.8 [18.6-22.6] vs. 22.8 [20.9-24.7] mmol/L; P=0.01). The lactate concentration was significantly higher in the NPE group (54.0 [40.3-61.0] mg/dL) than in the non-NPE group (28.0 [17.0-37.5] mg/dL; P<0.001). Multivariable regression analysis indicated that younger age and higher glucose and lactate levels were significantly associated with the early onset of NPE in patients with SAH. CONCLUSION The present findings indicate that an increased serum lactate level, occurring within 1 hour of the ictus, is an independent factor associated with the early onset of NPE. Multicenter prospective studies are required to confirm our results.
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Affiliation(s)
- Etsuko Satoh
- Department of Emergency and Critical Care Medicine, Nippon Medical School
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16
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Sheriff S, Kadeer N, Friend LA, James JH, Alexander JW, Balasubramaniam A. Des-acyl-ghrelin (DAG) normalizes hyperlactacidemia and improves survival in a lethal rat model of burn trauma. Peptides 2014; 60:1-7. [PMID: 25063053 DOI: 10.1016/j.peptides.2014.07.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 07/14/2014] [Accepted: 07/14/2014] [Indexed: 12/17/2022]
Abstract
Critical illness, including burn injury, results in elevated plasma lactate levels. Dysregulation of PI3K/Akt signaling has been shown to play a predominant role in the inactivation of skeletal muscle PDC and, hence, in hyperlactacidemia in rat models of sepsis and endotoxemia. This observation, and our previous finding that DAG can reverse burn-induced skeletal muscle proteolysis through the activation of PI3K/Akt pathway, led us to hypothesize that DAG may also attenuate hyperlactacidemia in burn injury. Our investigations revealed that burn injury significantly elevated both skeletal muscle lactate production and plasma lactate levels. Moreover, this was accompanied in skeletal muscle by a 5-7 fold increase in mRNA expression of pyruvate dehydrogenase kinases (PDK) 2 and 4, and a ∼30% reduction in PDC activity. DAG treatment of burn rats completely normalized not only the mRNA expression of the PDKs and PDC activity, but also hyperlactacidemia within 24h of burn injury. DAG also normalized epinephrine-induced lactate production by isolated skeletal muscles from normal rats. Moreover, DAG also improved survival in a lethal rat model of burn trauma. These findings with DAG may have clinical implications because chances of survival for critically ill patients are greatly improved if plasma lactate levels are normalized within 24h of injury.
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Affiliation(s)
- Sulaiman Sheriff
- Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267, USA; Shriners Hospital for Children, 3229 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Nijiati Kadeer
- Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267, USA; Shriners Hospital for Children, 3229 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Lou Ann Friend
- Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267, USA; Shriners Hospital for Children, 3229 Burnet Avenue, Cincinnati, OH 45229, USA
| | - J Howard James
- Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267, USA; Shriners Hospital for Children, 3229 Burnet Avenue, Cincinnati, OH 45229, USA
| | - J Wesley Alexander
- Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267, USA; Shriners Hospital for Children, 3229 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Ambikaipakan Balasubramaniam
- Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267, USA; Shriners Hospital for Children, 3229 Burnet Avenue, Cincinnati, OH 45229, USA; Cincinnati Veterans Affairs Medical Center, 3200 Vine Street, Cincinnati, OH 45220, USA.
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17
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Initial venous lactate levels in patients with isolated penetrating extremity trauma: a retrospective cohort study. Eur J Trauma Emerg Surg 2014; 41:203-9. [PMID: 26038266 DOI: 10.1007/s00068-014-0442-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 08/05/2014] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Elevated initial lactate levels have been shown to be associated with severe injury in trauma patients, but some patients who do not appear to be in shock also presented with elevated lactate levels. We hypothesized that in hemodynamically stable patients with isolated penetrating extremity trauma, initial lactate level does not predict clinically significant bleeding. METHODS A 5-year institutional database review was performed. Hemodynamically stable patients (HR < 101, SBP > 90) with isolated penetrating extremity trauma with an initial lactate sent were included. The exposure of interest was captured as a dichotomous variable by initial lactate level normal (N ≤ 2.2 mEq/L), elevated (E > 2.2 mEq/L). The primary outcome measurement was clinically significant bleeding, defined by need for intervention (operation, angioembolization, or transfusion) or laboratory evidence of bleeding (presenting Hg < 7 g/dL, or Hg decrease by >2 g/dL/24 h). Chi-squared and Mann-Whitney tests were used to compare variables. RESULTS A total of 132 patients were identified. There were no differences in demographics or mechanism of injury between the N (n = 43, 7%) and E (n = 89, 14%) groups. Median lactate levels were 1.6 (IQR 1.2-1.9) mEq/dL vs. 3.8 (IQR 2.8-5.2) in the N and E groups, p < 0.001. Lactate was elevated in 89 (67%) patients but was not associated with clinically significant bleeding (37% elevated vs. 39 % not elevated p = 0.82). CONCLUSIONS In hemodynamically stable patients with isolated penetrating trauma to the extremity, elevated initial venous lactate levels (>2.2 mEq/L) are not associated with bleeding or need for interventions. Clinical judgment remains the gold standard for evaluation and management of these patients.
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Wiggans MG, Starkie T, Shahtahmassebi G, Woolley T, Birt D, Erasmus P, Anderson I, Bowles MJ, Aroori S, Stell DA. Serum arterial lactate concentration predicts mortality and organ dysfunction following liver resection. Perioper Med (Lond) 2013; 2:21. [PMID: 24472571 PMCID: PMC3964326 DOI: 10.1186/2047-0525-2-21] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 09/19/2013] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The aim of this study was to determine if the post-operative serum arterial lactate concentration is associated with mortality, length of hospital stay or complications following hepatic resection. METHODS Serum lactate concentration was recorded at the end of liver resection in a consecutive series of 488 patients over a seven-year period. Liver function, coagulation and electrolyte tests were performed post-operatively. Renal dysfunction was defined as a creatinine rise of >1.5x the pre-operative value. RESULTS The median lactate was 2.8 mmol/L (0.6 to 16 mmol/L) and was elevated (≥2 mmol/L) in 72% of patients. The lactate concentration was associated with peak post-operative bilirubin, prothrombin time, renal dysfunction, length of hospital stay and 90-day mortality (P < 0.001). The 90-day mortality in patients with a post-operative lactate ≥6 mmol/L was 28% compared to 0.7% in those with lactate ≤2 mmol/L. Pre-operative diabetes, number of segments resected, the surgeon's assessment of liver parenchyma, blood loss and transfusion were independently associated with lactate concentration. CONCLUSIONS Initial post-operative lactate concentration is a useful predictor of outcome following hepatic resection. Patients with normal post-operative lactate are unlikely to suffer significant hepatic or renal dysfunction and may not require intensive monitoring or critical care.
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Affiliation(s)
- Matthew G Wiggans
- Hepatobiliary Surgery, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Plymouth, Devon PL6 8DH, UK.,Peninsula College of Medicine and Dentistry, University of Exeter and Plymouth University, Research Way, Plymouth, Devon PL6 8BU, UK
| | - Tim Starkie
- Department of Anaesthetics, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Plymouth, Devon PL6 8DH, UK
| | - Golnaz Shahtahmassebi
- Centre for Health Statistics, Tamar Science Park, Davy Road, Plymouth, Devon PL6 8BX, UK
| | - Tom Woolley
- Department of Anaesthetics, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Plymouth, Devon PL6 8DH, UK
| | - David Birt
- Department of Anaesthetics, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Plymouth, Devon PL6 8DH, UK
| | - Paul Erasmus
- Department of Anaesthetics, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Plymouth, Devon PL6 8DH, UK
| | - Ian Anderson
- Department of Anaesthetics, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Plymouth, Devon PL6 8DH, UK
| | - Matthew J Bowles
- Hepatobiliary Surgery, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Plymouth, Devon PL6 8DH, UK
| | - Somaiah Aroori
- Hepatobiliary Surgery, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Plymouth, Devon PL6 8DH, UK
| | - David A Stell
- Hepatobiliary Surgery, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Plymouth, Devon PL6 8DH, UK.,Peninsula College of Medicine and Dentistry, University of Exeter and Plymouth University, Research Way, Plymouth, Devon PL6 8BU, UK
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Stillion JR, Fletcher DJ. Admission base excess as a predictor of transfusion requirement and mortality in dogs with blunt trauma: 52 cases (2007-2009). J Vet Emerg Crit Care (San Antonio) 2013; 22:588-94. [PMID: 23110572 DOI: 10.1111/j.1476-4431.2012.00798.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the ability of admission base excess (ABE) to predict blood transfusion requirement and mortality in dogs following blunt trauma. DESIGN Retrospective study 2007-2009. SETTING University Veterinary Teaching Hospital. ANIMALS Fifty-two dogs admitted to the intensive care unit for treatment following blunt trauma. MEASUREMENTS AND MAIN RESULTS Animals requiring red blood cell transfusion (N = 8) had significantly lower ABE than those not requiring transfusion (N = 44; median base excess [BE] = -8.4 versus -4.7, P = .0034), while there was no difference in admission packed cell volume (PCV) or age. Animals that died or were euthanized due to progression of signs (N = 5) had lower median ABE than those that survived (N = 47; median BE = -7.3 versus -4.9, P = 0.018). Admission PCV and age were not significantly different between survivors and nonsurvivors. Receiver operator characteristic curve analysis showed an ABE cutoff of -6.6 was 88% sensitive and 73% specific for transfusion requirement (P < 0.001), and a cutoff of -7.3 was 81% sensitive and 80% specific for survival (P < 0.001). Multivariate logistic regression analysis demonstrated that ABE was a predictor of transfusion requirement that was independent of overall severity of injury as measured by the Animal Triage Trauma (ATT) score, but a similar analysis showed that only ATT was an independent predictor of survival. CONCLUSIONS The ABE in dogs with blunt trauma was a predictor of mortality and blood transfusion requirement within 24 hours.
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Affiliation(s)
- Jenefer R Stillion
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA
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20
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COLDING PD, KOLSTRUP LM, HYLDEBRANDT JA, SCHMIDT MR, BØTKER HE, RAVN HB. Metabolic effects of three different inotropic strategies in the newborn piglet myocardium. Acta Anaesthesiol Scand 2013. [PMID: 23186323 DOI: 10.1111/aas.12005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Neonates undergoing congenital heart surgery frequently need post-operative inotropic support. Knowledge about the effect of inotropes on myocardial metabolism in the newborn heart is limited, and the choice of inotropic therapy is based mainly on evidence from studies in adults. The aim of this study was to compare the effect of three inotropic strategies on the myocardial metabolism in a neonatal pig model. METHODS Newborn piglets were randomised to intravenous infusions with: adrenaline and milrinone; dopamine and milrinone; dobutamine in haemodynamically equivalent doses; or isotonic saline, through 3 h. Microdialysis catheters were inserted in the myocardium of the left and right ventricle, and concentrations of lactate, pyruvate, glycerol, and glucose were measured in the microdialysate. In myocardial biopsies, tissue lactate and intracellular glycogen concentrations were determined, and arterial blood samples were analysed for lactate and glucose. RESULTS No statistically significant differences were observed in haemodynamics between the three interventions. Metabolic variables demonstrated a consistent increase in lactate concentration in blood, myocardial dialysate, and biopsies in milrinone-adrenaline-treated animals. The lactate concentration remained stable in all other groups in all samples. The myocardial lactate/pyruvate ratio did not increase and was not significantly different between groups. CONCLUSION Milrinone and adrenaline induced significantly higher lactate levels in neonatal piglets. The increase was not caused by myocardial ischaemia, but rather due to a beta-stimulation-induced glycolysis.
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Affiliation(s)
- P. D. COLDING
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Skejby; Denmark
| | - L. M. KOLSTRUP
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Skejby; Denmark
| | | | - M. R. SCHMIDT
- Department of Cardiology; Aarhus University Hospital; Skejby; Denmark
| | - H. E. BØTKER
- Department of Cardiology; Aarhus University Hospital; Skejby; Denmark
| | - H. B. RAVN
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Skejby; Denmark
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Dunkel B, Kapff JE, Naylor RJ, Boston R. Blood lactate concentrations in ponies and miniature horses with gastrointestinal disease. Equine Vet J 2013; 45:666-70. [PMID: 23451985 DOI: 10.1111/evj.12043] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 12/28/2012] [Indexed: 11/28/2022]
Abstract
REASONS FOR PERFORMING STUDY Clinical impression suggested that pony and miniature breeds (collectively referred to as ponies) presenting to a referral hospital for investigation of gastrointestinal disease had higher blood lactate concentrations on admission than large breed horses. OBJECTIVES The study tested the hypothesis that ponies with gastrointestinal disease had higher blood lactate concentrations on admission than large breed horses with similar disease severity. STUDY DESIGN Retrospective case-control study. METHODS Medical records from September 2006 to July 2011 were reviewed for ponies with a primary presenting complaint of gastrointestinal disease. Two larger breed horses with gastrointestinal disease were selected as controls for each case. Data collected included case details, historical and clinicopathological findings, diagnosis and outcome. RESULTS Information was collected on 50 ponies and 100 horses. Ponies had higher mean ± s.d. respiratory rates (27 ± 13 vs. 21 ± 13 beats/min; P = 0.01) and rectal temperatures (37.9 ± 0.6 vs. 37.4 ± 0.6°C; P = 0.006) and a longer median duration of clinical signs prior to presentation (10 h [1-72 h] vs. 6 h [1-120]; P<0.001). Median blood lactate concentrations on admission were higher in ponies than in horses (2.8 mmol/l [0.7-18.0] vs. 1.6 mmol/l [0.4-8.1]; P = 0.001). All other parameters relating to colic severity were not significantly different between groups, although more horses underwent exploratory laparotomy (19/50 ponies and 55/100 horses; P = 0.05). Median blood lactate concentrations in ponies with large intestinal disease, nonstrangulating lesions, undergoing medical treatment and surviving ponies were significantly higher than in horses in the same category. In contrast to horses, no differences in blood lactate concentrations exist between ponies with medical vs. surgical treatment, strangulating and nonstrangulating lesions and surviving and nonsurviving ponies. CONCLUSION AND POTENTIAL RELEVANCE Ponies might present with higher blood lactate concentrations than horses and might falsely be suspected of having a surgical lesion or a poorer prognosis if veterinarians are not aware of breed differences.
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Affiliation(s)
- B Dunkel
- Department of Veterinary Clinical Sciences, The Royal Veterinary College, UK
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Lindsay AJ, Xu M, Sessler DI, Blackstone EH, Bashour CA. Lactate clearance time and concentration linked to morbidity and death in cardiac surgical patients. Ann Thorac Surg 2012; 95:486-92. [PMID: 22959571 DOI: 10.1016/j.athoracsur.2012.07.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 07/05/2012] [Accepted: 07/10/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Early predictors of morbidity after cardiac operations are lacking. Elevated lactate concentrations in the immediate postoperative period reflect unmet metabolic demand and may be associated with outcome. This study examined the association between early plasma lactate concentrations and outcome after cardiac operations. METHODS As a retrospective cohort investigation, patient information was obtained from the Cardiovascular Information and the Anesthesiology Institute's patient registries. Inclusion criteria were all adult cardiac surgical patients undergoing isolated coronary artery bypass grafting or valve procedures, or coronary artery bypass grafting with a valve procedure, from January 1, 2008, to August 7, 2008 (arterial lactate values were added to the patient registry beginning January 1, 2008). RESULTS Lactate concentrations during the initial 12 postoperative hours of a patient's stay in the cardiovascular intensive care unit were averaged (mean lactate concentration), and linear regression concentrations over time were used to predict when the lactate concentration would reach 1.5 mmol/L in individual patients (predicted lactate clearance time). We also considered the product of the mean and clearance (product value). Predicted lactate clearance time, mean lactate concentration, and product value were associated with any type of reoperation, death, and a set of composite outcomes (p < 0.001 for each). The accuracy of these indices was moderate to good, with the highest C statistic (for product value) being 0.82. CONCLUSIONS Predicted lactate clearance time, mean lactate concentration, and product value are each associated with death, any type of reoperation, and a set of composite outcomes in patients undergoing coronary artery bypass grafting or valve operations, or both. Product value provided the best early prognostic guidance in individual patients.
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Affiliation(s)
- Aaron J Lindsay
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio 44195, USA
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Kruse O, Grunnet N, Barfod C. Blood lactate as a predictor for in-hospital mortality in patients admitted acutely to hospital: a systematic review. Scand J Trauma Resusc Emerg Med 2011; 19:74. [PMID: 22202128 PMCID: PMC3292838 DOI: 10.1186/1757-7241-19-74] [Citation(s) in RCA: 185] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Accepted: 12/28/2011] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Using blood lactate monitoring for risk assessment in the critically ill patient remains controversial. Some of the discrepancy is due to uncertainty regarding the appropriate reference interval, and whether to perform a single lactate measurement as a screening method at admission to the hospital, or serial lactate measurements. Furthermore there is no consensus whether the sample should be drawn from arterial, peripheral venous, or capillary blood. The aim of this review was: 1) To examine whether blood lactate levels are predictive for in-hospital mortality in patients in the acute setting, i.e. patients assessed pre-hospitally, in the trauma centre, emergency department, or intensive care unit. 2) To examine the agreement between arterial, peripheral venous, and capillary blood lactate levels in patients in the acute setting. METHODS We performed a systematic search using PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and CINAHL up to April 2011. 66 articles were considered potentially relevant and evaluated in full text, of these ultimately 33 articles were selected. RESULTS AND CONCLUSION The literature reviewed supported blood lactate monitoring as being useful for risk assessment in patients admitted acutely to hospital, and especially the trend, achieved by serial lactate sampling, is valuable in predicting in-hospital mortality. All patients with a lactate at admission above 2.5 mM should be closely monitored for signs of deterioration, but patients with even lower lactate levels should be considered for serial lactate monitoring. The correlation between lactate levels in arterial and venous blood was found to be acceptable, and venous sampling should therefore be encouraged, as the risk and inconvenience for this procedure is minimal for the patient. The relevance of lactate guided therapy has to be supported by more studies.
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Affiliation(s)
- Ole Kruse
- Faculty of Health Sciences, University of Copenhagen, Denmark
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Montmany Vioque S, Navarro Soto S, Rebasa Cladera P, Luna Aufroy A, Gómez Díaz C, Llaquet Bayo H. [Measurement of lactic acid in multiple injury patients and its usefulness as a predictor of multiorgan failure and mortality]. Cir Esp 2011; 90:107-13. [PMID: 22206654 DOI: 10.1016/j.ciresp.2011.07.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 07/07/2011] [Accepted: 07/16/2011] [Indexed: 10/14/2022]
Abstract
INTRODUCTION The use of lactic acid as marker of occult hyperfusion and its relationship with multiorgan failure (MOF) and/or mortality is a subject of debate. MATERIAL AND METHOD A prospective study was conducted on multiple injury patients over 16 years of age in critical care areas. The lactic acid was measured at the beginning and at 24 hours of the trauma and associating it with the patient morbidity and mortality. RESULTS A total of 342 patients, with a mean injury severity score of 24.1, were included. The patients who survived had an initial, and 24 hours after the trauma, lactic acid of 27.8 mg/dl and 17.9 mg/dl, respectively, (normal values less than 22 mg/dl), increasing to 36.5mg/dl and 40.2mg/dl, respectively, in those who died. There were no differences between the initial lactic acid in patients with and without MOF, being increased at 24 hours in those who had MOF (17.8 vs 26.7). The patients with a lactic acid that got worse or remained abnormal at 24 hours had a higher mortality than those in which it remained the same or improved (25% - 17.1% vs 6.3% - 0.8%), with the percentage of patients with MOF also increasing (40.6% - 32.8% vs 14.9% - 11.1%). In haemodynamically stable patients, there was also a higher mortality when the lactic acid got worse or remained abnormal in the first 24 hours (23.8% - 19.2% vs 8.8% - 0%), as well as a higher percentage of MOF (38.1% - 26.9% vs 10.9% - 7.6%). CONCLUSIONS The lactic acid results in the first 24 hours of the multiple injury patient are associated with mortality and MOF, even when the patient is haemodynamically stable.
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Affiliation(s)
- Sandra Montmany Vioque
- Servicio de cirugía general y del aparato digestivo, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, España.
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A prospective multicenter cohort study of the association between global tissue hypoxia and coagulation abnormalities during early sepsis resuscitation. Crit Care Med 2010; 38:1092-100. [DOI: 10.1097/ccm.0b013e3181cf6fbc] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Torgersen C, Schmittinger CA, Wagner S, Ulmer H, Takala J, Jakob SM, Dünser MW. Hemodynamic variables and mortality in cardiogenic shock: a retrospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R157. [PMID: 19799772 PMCID: PMC2784383 DOI: 10.1186/cc8114] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Revised: 09/01/2009] [Accepted: 10/02/2009] [Indexed: 12/15/2022]
Abstract
Introduction Despite the key role of hemodynamic goals, there are few data addressing the question as to which hemodynamic variables are associated with outcome or should be targeted in cardiogenic shock patients. The aim of this study was to investigate the association between hemodynamic variables and cardiogenic shock mortality. Methods Medical records and the patient data management system of a multidisciplinary intensive care unit (ICU) were reviewed for patients admitted because of cardiogenic shock. In all patients, the hourly variable time integral of hemodynamic variables during the first 24 hours after ICU admission was calculated. If hemodynamic variables were associated with 28-day mortality, the hourly variable time integral of drops below clinically relevant threshold levels was computed. Regression models and receiver operator characteristic analyses were calculated. All statistical models were adjusted for age, admission year, mean catecholamine doses and the Simplified Acute Physiology Score II (excluding hemodynamic counts) in order to account for the influence of age, changes in therapies during the observation period, the severity of cardiovascular failure and the severity of the underlying disease on 28-day mortality. Results One-hundred and nineteen patients were included. Cardiac index (CI) (P = 0.01) and cardiac power index (CPI) (P = 0.03) were the only hemodynamic variables separately associated with mortality. The hourly time integral of CI drops <3, 2.75 (both P = 0.02) and 2.5 (P = 0.03) L/min/m2 was associated with death but not that of CI drops <2 L/min/m2 or lower thresholds (all P > 0.05). The hourly time integral of CPI drops <0.5-0.8 W/m2 (all P = 0.04) was associated with 28-day mortality but not that of CPI drops <0.4 W/m2 or lower thresholds (all P > 0.05). Conclusions During the first 24 hours after intensive care unit admission, CI and CPI are the most important hemodynamic variables separately associated with 28-day mortality in patients with cardiogenic shock. A CI of 3 L/min/m2 and a CPI of 0.8 W/m2 were most predictive of 28-day mortality. Since our results must be considered hypothesis-generating, randomized controlled trials are required to evaluate whether targeting these levels as early resuscitation endpoints can improve mortality in cardiogenic shock.
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Affiliation(s)
- Christian Torgersen
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria.
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Levosimendan: A New Therapeutic Option in the Treatment of Primary Graft Dysfunction After Heart Transplantation. J Heart Lung Transplant 2009; 28:501-4. [DOI: 10.1016/j.healun.2009.01.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2008] [Revised: 11/11/2008] [Accepted: 01/14/2009] [Indexed: 11/19/2022] Open
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Edner AH, Essén-Gustavsson B, Nyman GC. Metabolism during anaesthesia and recovery in colic and healthy horses: a microdialysis study. Acta Vet Scand 2009; 51:10. [PMID: 19284560 PMCID: PMC2660341 DOI: 10.1186/1751-0147-51-10] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2008] [Accepted: 03/10/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Muscle metabolism in horses has been studied mainly by analysis of substances in blood or plasma and muscle biopsy specimens. By using microdialysis, real-time monitoring of the metabolic events in local tissue with a minimum of trauma is possible. There is limited information about muscle metabolism in the early recovery period after anaesthesia in horses and especially in the colic horse. The aims were to evaluate the microdialysis technique as a complement to plasma analysis and to study the concentration changes in lactate, pyruvate, glucose, glycerol, and urea during anaesthesia and in the recovery period in colic horses undergoing abdominal surgery and in healthy horses not subjected to surgery. METHODS Ten healthy university-owned horses given anaesthesia alone and ten client-owned colic horses subjected to emergency abdominal surgery were anaesthetised for a mean (range) of 230 min (193-273) and 208 min (145-300) respectively. Venous blood samples were taken before anaesthesia. Venous blood sampling and microdialysis in the gluteal muscle were performed during anaesthesia and until 24 h after anaesthesia. Temporal changes and differences between groups were analysed with an ANOVA for repeated measures followed by Tukey Post Hoc test or Planned Comparisons. RESULTS Lactate, glucose and urea, in both dialysate and plasma, were higher in the colic horses than in the healthy horses for several hours after recovery to standing. In the colic horses, lactate, glucose, and urea in dialysate, and lactate in plasma increased during the attempts to stand. The lactate-to-pyruvate ratio was initially high in sampled colic horses but decreased over time. In the colic horses, dialysate glycerol concentrations varied considerably whereas in the healthy horses, dialysate glycerol was elevated during anaesthesia but decreased after standing. In both groups, lactate concentration was higher in dialysate than in plasma. The correspondence between dialysate and plasma concentrations of glucose, urea and glycerol varied. CONCLUSION Microdialysis proved to be suitable in the clinical setting for monitoring of the metabolic events during anaesthesia and recovery. It was possible with this technique to show greater muscle metabolic alterations in the colic horses compared to the healthy horses in response to regaining the standing position.
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Tiniakov R, Scrogin KE. The spleen is required for 5-HT1A receptor agonist-mediated increases in mean circulatory filling pressure during hemorrhagic shock in the rat. Am J Physiol Regul Integr Comp Physiol 2009; 296:R1392-401. [PMID: 19244581 DOI: 10.1152/ajpregu.91055.2008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The 5-HT(1A) receptor agonist, 8- OH-DPAT, increases whole body venous tone (mean circulatory filling pressure; MCFP), and attenuates metabolic acidosis in a rat model of unresuscitated hemorrhagic shock. To determine whether improved acid-base balance was associated with sympathetic activation and venous constriction, MCFP, sympathetic activity (SA), and blood gases were compared in hemorrhaged rats following administration of 5-HT(1A) receptor agonist 8-OH-DPAT, the arterial vasoconstrictor arginine vasopressin (AVP), or saline. To further determine whether protection of acid-base balance was dependent on splenic contraction and blood mobilization, central venous pressure (CVP), MCFP, and blood gases were determined during hemorrhage and subsequent 8-OH-DPAT-administration in rats subjected to real or sham splenectomy. Subjects were hemorrhaged to an arterial pressure of 50 mmHg for 25 min and subsequently were treated with 8-OH-DPAT (30 nmol/kg iv), AVP titrated to match the pressor effect of 8-OH-DPAT (approximately 2 ng/min iv), or infusion of normal saline. 8-OH-DPAT increased MAP, CVP, MCFP, and SA, and decreased lactate accumulation. AVP did not affect CVP or SA, but raised MCFP slightly to a level intermediate between 8-OH-DPAT- and saline-treated rats. Infusion of AVP also produced a modest protection against metabolic acidosis. Splenectomy prevented the rise in CVP, MCFP, and protection against metabolic acidosis produced by 8-OH-DPAT but had no effect on the immediate pressor response to the drug. Together, the data indicate that 8-OH-DPAT produces a pattern of cardiovascular responses consistent with a sympathetic-mediated venoconstriction that is, in part, responsible for the drug's beneficial effect on acid-base balance. Moreover, blood mobilization stimulated by the spleen is required for the beneficial effects of 8-OH-DPAT.
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Affiliation(s)
- Ruslan Tiniakov
- Department of Pharmacology and Experimental Therapeutics, Loyola University Chicago, Stritch School of Medicine, Maywood, IL 60153, USA
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Ciglitazone ameliorates lung inflammation by modulating the inhibitor kappaB protein kinase/nuclear factor-kappaB pathway after hemorrhagic shock. Crit Care Med 2008; 36:2849-57. [PMID: 18828195 DOI: 10.1097/ccm.0b013e318187810e] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Peroxisome proliferator-activated receptor-gamma is a ligand-activated transcription factor. Ciglitazone, a peroxisome proliferator-activated receptor-gamma ligand, has been shown to provide beneficial effects in experimental models of sepsis and ischemia/reperfusion injury. We investigated the effects of ciglitazone on lung inflammation after severe hemorrhage. DESIGN Prospective, laboratory study, rodent model of hemorrhagic shock. SETTING University hospital laboratory. SUBJECTS Male rats. INTERVENTIONS Hemorrhagic shock was induced by withdrawing blood to a mean arterial pressure of 50 mm Hg. At 3 hrs after hemorrhage, rats were rapidly resuscitated by returning their shed blood. At the time of resuscitation and every hour thereafter, animals received ciglitazone (10 mg/kg) or vehicle intraperitoneally. Heart rate and mean arterial pressure were measured throughout the experiment. Plasma and lung tissue were collected for analysis up to 3 hrs after resuscitation. MEASUREMENTS AND MAIN RESULTS Ciglitazone treatment ameliorated mean arterial pressure, reduced lung injury, significantly blunted lung neutrophil infiltration, and lowered plasma interleukin-6, interleukin-10, and monocyte chemoattractant protein-1 levels. In a time course analysis, vehicle-treated rats had a significant increase in nuclear factor-kappaB DNA binding, which was preceded by increased inhibitor kappaB protein kinase activity and inhibitor kappaB alpha degradation in the lung. Treatment with ciglitazone significantly reduced inhibitor kappaB protein kinase activity and inhibitor kappaB alpha degradation and completely inhibited nuclear factor-kappaB DNA binding. This reduction of inhibitor kappaB protein kinase activity afforded by ciglitazone appeared to be a consequence of a physical interaction between peroxisome proliferator-activated receptor-gamma and increased inhibitor kappaB protein kinase. CONCLUSION Ciglitazone ameliorates the inflammatory response and may reduce lung injury after hemorrhagic shock. These protective effects appear to be mediated through inhibition of the inhibitor kappaB protein kinase/nuclear factor-kappaB pathway.
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Abstract
Three important issues concerning homeostasis in the acute care of trauma patients that are related directly to the stress response are hyperglycemia, lactic acidosis, and hypothermia. Recently, there has been a resurgence of interest in investigating the effects of aggressive thermal and glucose concentration and volume resuscitation on outcomes in critically ill and trauma patients. Significant reason exists to question the "conventional wisdom" relating to current approaches to restoring homeostasis in this patient population.
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Affiliation(s)
- Dimitry Baranov
- Department of Anesthesiology and Critical Care, Hospital of University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Reynolds PS, Barbee RW, Ward KR. Pharmaceutical metabolic down-regulation by protein synthesis inhibition in a conscious rat model. Resuscitation 2007; 73:446-58. [PMID: 17292527 DOI: 10.1016/j.resuscitation.2006.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2006] [Revised: 10/23/2006] [Accepted: 10/31/2006] [Indexed: 01/26/2023]
Abstract
Pharmaceutically induced metabolic down-regulation may be a useful therapeutic adjunct when tissue oxygen supply is restricted. We hypothesized that protein synthesis inhibition in a non-hibernating species should lower oxygen demand, resulting in aerobic metabolic rate depression at the whole animal level. We compared metabolic responses and measures of systemic oxygenation of conscious catheterized rats given either protein synthesis inhibition (PSI) agents or carrier controls (normal saline and DMSO). Core temperature was measured by implanted transmitters, and VO2 was determined in an open flow-through metabolic chamber at 25 degrees C. Mean arterial pressure MAP and heart rate HR were determined from arterial pressure transducer tracings; arterial blood gases and lactate were sampled every 15 min. PSI rats exhibited an immediate transient decline in VO2, followed by a secondary decline to new resting levels; VO2 for the first hour was significantly lower than that for rats receiving DMSO vehicle. Unlike controls, PSI rats showed an overall 3.5 degrees C decline in core temperature, coupled with increased arterial lactate. There were no differences in MAP and HR of PSI rats compared to controls. Although hypothermic response to toxic agents typical of rodents cannot be ruled out completely, the mild hypothermia and reduced VO2 exhibited by PSI rats may be partially attributed to the action of protein synthesis agents.
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Affiliation(s)
- Penny S Reynolds
- Department of Emergency Medicine, Virginia Commonwealth University Medical Center, Richmond, VA 23298-0401, USA.
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Trzeciak S, Dellinger RP, Chansky ME, Arnold RC, Schorr C, Milcarek B, Hollenberg SM, Parrillo JE. Serum lactate as a predictor of mortality in patients with infection. Intensive Care Med 2007; 33:970-7. [PMID: 17431582 DOI: 10.1007/s00134-007-0563-9] [Citation(s) in RCA: 236] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2006] [Accepted: 01/26/2007] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To determine the utility of an initial serum lactate measurement for identifying high risk of death in patients with infection. DESIGN AND SETTING Post-hoc analysis of a prospectively compiled registry in an urban academic hospital. PARTICIPANTS Patients with (a) a primary or secondary diagnosis of infection and (b) lactate measurement who were admitted over the 18 months following hospital-wide implementation of the Surviving Sepsis Campaign guideline for lactate measurement in patients with infection and possible severe sepsis. There were 1,177 unique patients, with an in-hospital mortality of 19%. MEASUREMENTS AND RESULTS Outcome measures included acute-phase (<or=3 days) death and in-hospital death. We defined lactate ranges a priori (low, 0.0-2.0; intermediate, 2.1-3.9; high, 4.0 mmol/l or above)--and tested for linear associations with mortality by one-way analysis of variance. We determined sensitivity/specificity, odds ratios, and likelihood ratios for a lactate >or=4.0 mmol/l and performed a Bayesian analysis to determine its impact on a full range (0.01-0.99) of hypothetical pretest probability estimates for death. In-hospital mortality was 15%, 25%, and 38% in low, intermediate, and high lactate groups, respectively. Acute-phase deaths and in-hospital deaths increased linearly with lactate. An initial lactate >or=4.0 mmol/l was associated with sixfold higher odds of acute-phase death; however, a lactate level less than 4 mmol/l had little impact on probability of death. CONCLUSIONS When broadly implemented in routine practice, measurement of lactate in patients with infection and possible sepsis can affect assessment of mortality risk. Specifically, an initial lactate >or=4.0 mmol/l substantially increases the probability of acute-phase death.
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Affiliation(s)
- Stephen Trzeciak
- UMDNJ-Robert Wood Johnson Medical School at Camden, Cooper University Hospital, Division of Cardiovascular Disease and Critical Care Medicine, One Cooper Plaza, Camden 08103, NJ, USA.
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Zeitlinger BS, Zeitlinger M, Leitner I, Müller M, Joukhadar C. Clinical scoring system for the prediction of target site penetration of antimicrobials in patients with sepsis. Clin Pharmacokinet 2007; 46:75-83. [PMID: 17201459 DOI: 10.2165/00003088-200746010-00004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVES The present study investigated the usefulness of routinely employed scoring systems in predicting tissue penetration of antimicrobials. In addition, a novel, easy to use scoring system was designed for the estimation of tissue penetration of antimicrobials in patients with sepsis. METHODS Tissue pharmacokinetics were assessed in skeletal muscle and subcutaneous adipose tissue by use of the microdialysis technique in 34 patients with sepsis. Tissue penetration of antimicrobials was retrospectively determined by the ratios of the area under the concentration-time curves (AUC) in soft tissues (AUCtissue) to the AUC in plasma (AUCplasma). Mortality and sepsis scores currently used in intensive care were consecutively calculated and correlated with the AUCtissue:AUCplasma ratio. Single laboratory and clinical parameters showing the highest correlation with tissue penetration were identified and used in the novel Tissue Penetration Prediction Score (TPPS). RESULTS The currently used scoring systems Simplified Acute Physiology Scores 3 (r=-0.33, p=0.006), Acute Physiology and Chronic Health Evaluation III (r=-0.27, p=0.03) and Sepsis-Related (or Sequential) Organ Failure Assessment (r=-0.32, p=0.01) showed significant overall correlations with tissue penetration. However, their predictive power for the concentrations of antimicrobials in muscle tissue was not satisfying. The parameters oxygen saturation, serum lactate concentration and the dose per time unit of norepinephrine (noradrenaline) administered showed the best correlation with tissue penetration and were used in the TPPS. Its overall correlation (r=-0.52, p=0.000007) as well as correlations for the concentrations of antimicrobials in muscle (r=-0.46, p=0.006) and adipose tissue (r=-0.59, p=0.0003) were better than the currently used scoring systems. CONCLUSION The TPPS may prove to be a powerful tool for the estimation of antimicrobial tissue penetration at the bedside in septic patients. This score may allow for adequate individual dose adjustment in septic patients. However, this needs to be verified in subsequent prospective clinical trials.
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Affiliation(s)
- Barbara S Zeitlinger
- Department of Clinical Pharmacology, Division of Clinical Pharmacokinetics, Medical University of Vienna, Vienna, Austria
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Affiliation(s)
- Elizabeth J. Bridges
- Elizabeth Bridges was formerly the deputy commander of the 59th Clinical Research Squadron and a senior nurse researcher at the 59th Medical Wing, Lackland Air Force Base, San Antonio, Tex. She is now an assistant professor at the University of Washington School of Nursing and a clinical nurse researcher at the University of Washington Medical Center, Seattle, Wash
| | - Susan Dukes
- Susan Dukes is a critical care clinical nurse specialist in the 759th Surgical Operations Squadron, Wilford Hall Medical Center, at Lackland Air Force Base
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Levy B, Gibot S, Franck P, Cravoisy A, Bollaert PE. Relation between muscle Na+K+ ATPase activity and raised lactate concentrations in septic shock: a prospective study. Lancet 2005; 365:871-5. [PMID: 15752531 DOI: 10.1016/s0140-6736(05)71045-x] [Citation(s) in RCA: 318] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hyperlactataemia during septic shock is often viewed as evidence of tissue hypoxia. However, this blood disorder is not usually correlated with indicators of perfusion or diminished with increased oxygen delivery. Muscles can generate lactate under aerobic conditions in a process linking glycolytic ATP supply to stimulation of Na+K+ ATPase. Using in-vivo microdialysis, we tested whether inhibition of Na+K+ ATPase can reduce muscle lactate. METHODS In 14 patients with septic shock, two microdialysis probes were inserted into the quadriceps muscles and infused with lactate-free Ringer's solution in the absence or presence of 10(-7) mol/L ouabain, a specific inhibitor of Na+K+ ATPase. We measured lactate and pyruvate concentrations in both the dialysate fluid and arterial blood samples. FINDINGS All patients had increased blood lactate concentrations (mean 4.0 mmol/L; SD 2.1). Lactate and pyruvate concentrations were consistently higher in muscle than in arteries during the study period, with a mean positive gradient of 1.98 mmol/L (SD 0.2; p=0.001) and 230 micromol/L (30; p=0.01), respectively. Ouabain infusion stopped over production of muscle lactate and pyruvate (p=0.0001). Muscle lactate to pyruvate ratios remained unchanged during ouabain infusion with no differences between blood and muscle. INTERPRETATION Skeletal muscle could be a leading source of lactate formation as a result of exaggerated aerobic glycolysis through Na+K+ ATPase stimulation during septic shock. Lactate clearance as an end-point of resuscitation could therefore prove useful. RELEVANCE TO CLINICAL PRACTICE In patients with septic shock, a high lactate concentration should be interpreted as a marker of disease, portending a bad outcome. The presence of hyperlactataemia in resuscitated septic patients should not be taken as proof of oxygen debt needing increases in systemic or regional oxygen transport to supranormal values. Lactate, instead of being regarded only as a marker of hypoxia, might be an important metabolic signal.
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Affiliation(s)
- Bruno Levy
- Service de Réanimation Médicale, Hôpital Central, 54035 Nancy, France.
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Abstract
Measurements of physiologic parameters, such as blood pressure or lactate concentration, are useful to detect occult derangements, such as tissue hypoxia and dysoxia. These tools are also useful in determining the effects of therapy. Monitoring techniques are now widely available for the intensive management of critically ill horses and foals. A number of these have evolved into noninvasive or minimally invasive devices and procedures and provide information that can be used for earlier and more dynamic therapeutic intervention. The goal of increased monitoring is to improve the level of care in the ICU; L ultimately. increased survival of critical patients is the motivation behind enhanced monitoring of physiology, with particular attention being paid to trends or alterations over time. This review highlights practical and informative monitoring tools and techniques and provides normal reference values from the literature.
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Affiliation(s)
- K Gary Magdesian
- Department of Medicine and Epidemiology, University of California at Davis, Davis, CA 95616, USA.
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Abstract
For much of the 20th century, lactate was largely considered a dead-end waste product of glycolysis due to hypoxia, the primary cause of the O2 debt following exercise, a major cause of muscle fatigue, and a key factor in acidosis-induced tissue damage. Since the 1970s, a 'lactate revolution' has occurred. At present, we are in the midst of a lactate shuttle era; the lactate paradigm has shifted. It now appears that increased lactate production and concentration as a result of anoxia or dysoxia are often the exception rather than the rule. Lactic acidosis is being re-evaluated as a factor in muscle fatigue. Lactate is an important intermediate in the process of wound repair and regeneration. The origin of elevated [lactate] in injury and sepsis is being re-investigated. There is essentially unanimous experimental support for a cell-to-cell lactate shuttle, along with mounting evidence for astrocyte-neuron, lactate-alanine, peroxisomal and spermatogenic lactate shuttles. The bulk of the evidence suggests that lactate is an important intermediary in numerous metabolic processes, a particularly mobile fuel for aerobic metabolism, and perhaps a mediator of redox state among various compartments both within and between cells. Lactate can no longer be considered the usual suspect for metabolic 'crimes', but is instead a central player in cellular, regional and whole body metabolism. Overall, the cell-to-cell lactate shuttle has expanded far beyond its initial conception as an explanation for lactate metabolism during muscle contractions and exercise to now subsume all of the other shuttles as a grand description of the role(s) of lactate in numerous metabolic processes and pathways.
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Affiliation(s)
- L B Gladden
- Department of Health and Human Performance, 2050 Memorial Coliseum, Auburn University, Auburn, AL 36849-5323, USA.
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