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Deulkar P, Singam A, Mudiganti VNKS, Jain A. Lactate Monitoring in Intensive Care: A Comprehensive Review of Its Utility and Interpretation. Cureus 2024; 16:e66356. [PMID: 39246930 PMCID: PMC11379417 DOI: 10.7759/cureus.66356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Accepted: 08/06/2024] [Indexed: 09/10/2024] Open
Abstract
Lactate monitoring is critical in managing critically ill patients in intensive care settings. Elevated lactate levels often signify underlying metabolic disturbances such as tissue hypoxia, anaerobic metabolism, or impaired lactate clearance, which are prevalent in conditions like sepsis, shock, and trauma. Understanding the physiological basis of lactate production and its significance in clinical practice is essential for interpreting its diagnostic and prognostic value. This comprehensive review aims to explore the utility of lactate monitoring across various critical care scenarios. It provides an overview of lactate's metabolic pathways, methods of measurement, and the clinical implications of interpreting lactate levels in different contexts. Additionally, the review discusses current evidence on lactate-guided therapeutic interventions and highlights challenges and limitations to their application. By synthesizing the existing literature and clinical insights, this review aims to enhance the understanding of the role of lactate monitoring in assessing disease severity, guiding treatment strategies, and predicting outcomes in critically ill patients. Ultimately, this review underscores the importance of integrating lactate monitoring into routine clinical practice to optimize patient care and improve clinical outcomes in intensive care settings.
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Affiliation(s)
- Pallavi Deulkar
- Critical Care Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute Of Higher Education and Research, Wardha, IND
| | - Amol Singam
- Critical Care Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute Of Higher Education and Research, Wardha, IND
| | - V N K Srinivas Mudiganti
- Critical Care Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute Of Higher Education and Research, Wardha, IND
| | - Abhishek Jain
- Critical Care Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute Of Higher Education and Research, Wardha, IND
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Llitjos JF, Carrol ED, Osuchowski MF, Bonneville M, Scicluna BP, Payen D, Randolph AG, Witte S, Rodriguez-Manzano J, François B. Enhancing sepsis biomarker development: key considerations from public and private perspectives. Crit Care 2024; 28:238. [PMID: 39003476 PMCID: PMC11246589 DOI: 10.1186/s13054-024-05032-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 07/10/2024] [Indexed: 07/15/2024] Open
Abstract
Implementation of biomarkers in sepsis and septic shock in emergency situations, remains highly challenging. This viewpoint arose from a public-private 3-day workshop aiming to facilitate the transition of sepsis biomarkers into clinical practice. The authors consist of international academic researchers and clinician-scientists and industry experts who gathered (i) to identify current obstacles impeding biomarker research in sepsis, (ii) to outline the important milestones of the critical path of biomarker development and (iii) to discuss novel avenues in biomarker discovery and implementation. To define more appropriately the potential place of biomarkers in sepsis, a better understanding of sepsis pathophysiology is mandatory, in particular the sepsis patient's trajectory from the early inflammatory onset to the late persisting immunosuppression phase. This time-varying host response urges to develop time-resolved test to characterize persistence of immunological dysfunctions. Furthermore, age-related difference has to be considered between adult and paediatric septic patients. In this context, numerous barriers to biomarker adoption in practice, such as lack of consensus about diagnostic performances, the absence of strict recommendations for sepsis biomarker development, cost and resources implications, methodological validation challenges or limited awareness and education have been identified. Biomarker-guided interventions for sepsis to identify patients that would benefit more from therapy, such as sTREM-1-guided Nangibotide treatment or Adrenomedullin-guided Enibarcimab treatment, appear promising but require further evaluation. Artificial intelligence also has great potential in the sepsis biomarker discovery field through capability to analyse high volume complex data and identify complex multiparametric patient endotypes or trajectories. To conclude, biomarker development in sepsis requires (i) a comprehensive and multidisciplinary approach employing the most advanced analytical tools, (ii) the creation of a platform that collaboratively merges scientific and commercial needs and (iii) the support of an expedited regulatory approval process.
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Affiliation(s)
- Jean-Francois Llitjos
- Open Innovation and Partnerships (OI&P), bioMérieux S.A., Marcy l'Etoile, France.
- Anesthesiology and Critical Care Medicine, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France.
| | - Enitan D Carrol
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool Institute of Infection Veterinary and Ecological Sciences, Liverpool, UK
- Department of Paediatric Infectious Diseases and Immunology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Marcin F Osuchowski
- Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, Vienna, Austria
| | - Marc Bonneville
- Medical and Scientific Affairs, Institut Mérieux, Lyon, France
| | - Brendon P Scicluna
- Department of Applied Biomedical Science, Faculty of Health Sciences, Mater Dei Hospital, University of Malta, Msida, Malta
- Centre for Molecular Medicine and Biobanking, University of Malta, Msida, Malta
| | - Didier Payen
- Paris 7 University Denis Diderot, Paris Sorbonne, Cité, France
| | - Adrienne G Randolph
- Departments of Anaesthesia and Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | | | | | - Bruno François
- Medical-Surgical Intensive Care Unit, Réanimation Polyvalente, Dupuytren University Hospital, CHU de Limoges, 2 Avenue Martin Luther King, 87042, Limoges Cedex, France.
- Inserm CIC 1435, Dupuytren University Hospital, Limoges, France.
- Inserm UMR 1092, Medicine Faculty, University of Limoges, Limoges, France.
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3
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Orellana G, Josef V, Parchim NF, Mitchell JA. Current state of sepsis resuscitation in critical care. Int Anesthesiol Clin 2023; 61:43-54. [PMID: 37622346 DOI: 10.1097/aia.0000000000000416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Affiliation(s)
- Gabriela Orellana
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
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Shang N, Li Q, Liu H, Li J, Guo S. Erector spinae muscle-based nomogram for predicting in-hospital mortality among older patients with severe community-acquired pneumonia. BMC Pulm Med 2023; 23:346. [PMID: 37710218 PMCID: PMC10500910 DOI: 10.1186/s12890-023-02640-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 09/07/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND No multivariable model incorporating erector spinae muscle (ESM) has been developed to predict clinical outcomes in older patients with severe community-acquired pneumonia (SCAP). This study aimed to construct a nomogram based on ESM to predict in-hospital mortality in patients with SCAP. METHODS Patients aged ≥ 65 years with SCAP were enrolled in this prospective observational study. Least absolute selection and shrinkage operator and multivariable logistic regression analyses were used to identify risk factors for in-hospital mortality. A nomogram prediction model was constructed. The predictive performance was evaluated using the concordance index (C-index), calibration curve, net reclassification improvement (NRI), integrated discrimination improvement (IDI), and decision curve analysis. RESULTS A total of 490 patients were included, and the in-hospital mortality rate was 36.1%. The nomogram included the following independent risk factors: mean arterial pressure, peripheral capillary oxygen saturation, Glasgow Coma Scale score (GCS), lactate, lactate dehydrogenase, blood urea nitrogen levels, and ESM cross-sectional area. Incorporating ESM into the base model with other risk factors significantly improved the C-index from 0.803 (95% confidence interval [CI], 0.761-0.845) to 0.836 (95% CI, 0.798-0.873), and these improvements were confirmed by category-free NRI and IDI. The ESM-based nomogram demonstrated a high level of discrimination, good calibration, and overall net benefits for predicting in-hospital mortality compared with the combination of confusion, urea, respiratory rate, blood pressure, and age ≥ 65 years (CURB-65), Pneumonia Severity Index (PSI), Acute Physiology and Chronic Health Evaluation II (APACHEII), and Sequential Organ Failure Assessment (SOFA). CONCLUSIONS The proposed ESM-based nomogram for predicting in-hospital mortality among older patients with SCAP may help physicians to promptly identify patients prone to adverse outcomes. TRIAL REGISTRATION This study was registered at www.chictr.org.cn (registration number Chi CTR-2300070377).
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Affiliation(s)
- Na Shang
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, 100020, China
- Department of Emergency Medicine, Capital Medical University School of Rehabilitation Medicine, Beijing Bo'Ai Hospital, China Rehabilitation Research Center, Beijing, 100068, China
| | - Qiujing Li
- Department of Emergency Medicine, Capital Medical University, Beijing Shijitan Hospital, Beijing, 100038, China
| | - Huizhen Liu
- Department of Emergency Medicine, Capital Medical University School of Rehabilitation Medicine, Beijing Bo'Ai Hospital, China Rehabilitation Research Center, Beijing, 100068, China
| | - Junyu Li
- Department of Emergency Medicine, Capital Medical University School of Rehabilitation Medicine, Beijing Bo'Ai Hospital, China Rehabilitation Research Center, Beijing, 100068, China
| | - Shubin Guo
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, 100020, China.
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Freeman DME, Ming DK, Wilson R, Herzog PL, Schulz C, Felice AKG, Chen YC, O’Hare D, Holmes AH, Cass AEG. Continuous Measurement of Lactate Concentration in Human Subjects through Direct Electron Transfer from Enzymes to Microneedle Electrodes. ACS Sens 2023; 8:1639-1647. [PMID: 36967522 PMCID: PMC10152478 DOI: 10.1021/acssensors.2c02780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Microneedle lactate sensors may be used to continuously measure lactate concentration in the interstitial fluid in a minimally invasive and pain-free manner. First- and second-generation enzymatic sensors produce a redox-active product that is electrochemically sensed at the electrode surface. Direct electron transfer enzymes produce electrons directly as the product of enzymatic action; in this study, a direct electron transfer enzyme specific to lactate has been immobilized onto a microneedle surface to create lactate-sensing devices that function at low applied voltages (0.2 V). These devices have been validated in a small study of human volunteers; lactate concentrations were raised and lowered through physical exercise and subsequent rest. Lactazyme microneedle devices show good agreement with concurrently obtained and analyzed serum lactate levels.
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Sandal ÖS, Ceylan G, Sarı F, Atakul G, Çolak M, Topal S, Soydan E, Karaarslan ÜU, Ağın H. Could lactate clearance be a marker of mortality in pediatric intensive care unit? Turk J Med Sci 2022; 52:1771-1778. [PMID: 36945991 PMCID: PMC10390184 DOI: 10.55730/1300-0144.5522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/09/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Hyperlactatemia is a common finding in critically ill patients and has significant prognostic implications. However, a single lactate measurement has not been correlated to mortality consistently. In this study, we aimed to correlate the clinical efficacy of lactate clearance for the prediction of mortality in pediatric intensive care unit patients. METHODS This retrospective observational study was performed in the pediatric intensive care unit in patients with lactate level >3 mmol/lt. Initial, 6th h, and 24th h lactate levels were recorded and lactate clearance was calculated using these values (lactate level at admission - level 6 h later × 100/lactate level at admission). RESULTS A total of 172 patients were included in the study. Forty-four out of 172 patients died. Median (IQR) lactate (mmol/L) at admission was low in those who survived in comparison to nonsurvivors 4.4 (3.1) vs. 5.75 (7.7) (p = 0.002). Clearance at 6th h was significantly lower in those who died (11.7%) than those who survived (36.7) (p = 0.001). 6th h lactate clearance level <20.7% predicted mortality with a sensitivity of 63.6% and specificity of 69.5% along with a positive predictive value of 41.8 and a negative predictive value of 84.8 (p = 0.004). Both lactate levels and lactate clearance values were significantly predictive factors for mortality (p < 0.05). Only a positive moderate correlation was found between the percentage of PRISM-IV % and 6th h lactate level. DISCUSSION The present study revealed that lactate clearance is a simple and rapid risk-stratification tool holding to be a potential biomarker of managing the treatment efficacy of children in the pediatric intensive care unit.
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Affiliation(s)
- Özlem Saraç Sandal
- Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Pediatrics Training and Research Hospital, İzmir, Turkey
| | - Gökhan Ceylan
- Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Pediatrics Training and Research Hospital, İzmir, Turkey
| | - Ferhat Sarı
- Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Pediatrics Training and Research Hospital, İzmir, Turkey
| | - Gülhan Atakul
- Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Pediatrics Training and Research Hospital, İzmir, Turkey
| | - Mustafa Çolak
- Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Pediatrics Training and Research Hospital, İzmir, Turkey
| | - Sevgi Topal
- Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Pediatrics Training and Research Hospital, İzmir, Turkey
| | - Ekin Soydan
- Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Pediatrics Training and Research Hospital, İzmir, Turkey
| | - Ünal Utku Karaarslan
- Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Pediatrics Training and Research Hospital, İzmir, Turkey
| | - Hasan Ağın
- Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Pediatrics Training and Research Hospital, İzmir, Turkey
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Zeng J, Wan J, He W, Zhu Y, Zeng H, Liu P, Gong M, Liu F, Shao Q, Xia L, Zhu Y, Chen Y, Lu N. Prognostic Value of Arterial Lactate Metabolic Clearance Rate in Moderate and Severe Acute Pancreatitis. DISEASE MARKERS 2022; 2022:9233199. [PMID: 36408464 PMCID: PMC9668450 DOI: 10.1155/2022/9233199] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 10/19/2022] [Indexed: 05/22/2024]
Abstract
PURPOSE High lactate levels at hospital admission are significantly associated with poor prognosis in acute pancreatitis patients. Early high lactate clearance is a vital marker for predicting persistent organ failure and mortality in critical illness; however, its value in acute pancreatitis remains unclear. METHOD Data were collected from patients who were diagnosed with moderately severe acute pancreatitis and severe acute pancreatitis from January 2017 to December 2020. Initial lactate (within 2 hours after admission) and repeat lactate at 24 hours after admission were measured to determine lactate clearance. Low clearance was defined as a reduction in repeat lactate of less than 30% compared to the first measurement. High clearance was defined as a repeat lactate decrease ≥30% of the first measurement or both first and second lactate levels <2 mmol/L. Baseline data, laboratory data, mortality rate, persistent organ failure rate, and other outcomes such as the incidence of septic pancreatic necrosis and sepsis and the length of hospital stay and intensive care unit (ICU) stay were compared in the low and high lactate clearance groups. Multivariate logistic regression analyses were used to assess the value of lactate clearance for predicting death. RESULT Among 4425 acute pancreatitis patients, 3040 patients were diagnosed with moderate or severe acute pancreatitis, and 1028 patients had initial lactate measured. Finally, 390 patients who had initial and 24-hour repeat lactate data were included in the study. Patients who had elevated initial lactate had poor outcomes, and 51 patients in the initial elevated lactate group died. In the lactate normalization group analysis, 293 patients had 24-hour lactate normalization; compared with patients in the nonnormalization group, they had a lower rate of mortality (12.6% vs. 33%). In the lactate clearance group analysis, 70 (21.9%) patients had a low clearance after 24 hours; compared with patients in the high clearance group, they had a higher rate of developing persistent multiorgan failure (P = 0.045), and the incidence of death was higher (15% vs. 28.6%, P = 0.007). Multivariate logistic analysis showed that 24-hour lactate clearance (OR: 2.007; 95% CI:1.032-3.903, P = 0.04), elevated initial lactate (OR: 2.011; 95% CI:1.023-3.953, P = 0.043), blood urea nitrogen (OR: 2.316; 95% CI:1.061-5.056, P = 0.035), and white blood count (OR: 1.982; 95% CI:1.026-3.829, P = 0.042) were independent predictors of hospital mortality. CONCLUSION The 24-hour clearance of lactate is a reliable marker to predict the outcome of moderate and severe acute pancreatitis, and low lactate clearance may indicate that the patient's condition will worsen, requiring aggressive treatments to improve patient outcomes.
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Affiliation(s)
- Jiji Zeng
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, China
| | - Jianhua Wan
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, China
| | - Wenhua He
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, China
| | - Yong Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, China
| | - Hao Zeng
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, China
| | - Pi Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, China
| | - Min Gong
- Department of Digestive Internal Medicine, Southern Medical University Pingxiang Hospital, Pingxiang, China
| | - Fen Liu
- Department of Intensive Care Unit, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qiang Shao
- Department of Intensive Care Unit, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Liang Xia
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, China
| | - Yin Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, China
| | - Youxiang Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, China
| | - Nonghua Lu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, China
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Chen S, Liu M, Feng D, Lv X, Wei J. A Novel Strategy for Predicting 72-h Mortality After Admission in Patients With Polytrauma: A Study on the Development and Validation of a Web-Based Calculator. Front Med (Lausanne) 2022; 9:799811. [PMID: 35492331 PMCID: PMC9046941 DOI: 10.3389/fmed.2022.799811] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 03/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background Early and accessible screening of patients with polytrauma at a high risk of hospital death is essential. The purpose of this research was to seek an accurate and convenient solution to predict deaths occurring within 72 h after admission of these patients. Methods A secondary analysis was conducted on 3,075 patients with polytrauma from the Dryad database. We imputed missing values in eligible individuals with the k-nearest neighbor algorithm and then randomly stratified them into the training group (n = 2,461) and the validation group (n = 614) based on a proportion of 8:2. The restricted cubic spline, univariate, backward stepwise, and multivariate logistic regression methods were employed to determine the suitable predictors. Calibration and receiver operating characteristic (ROC) curves were applied to assess the calibration and discrimination of the obtained model. The decision curve analysis was then chosen as the measure to examine the clinical usage. Results Age, the Glasgow Coma Scale score, the Injury Severity Score, base excess, and the initial lactate level were inferred as independent prognostic factors related to mortality. These factors were then integrated and applied to construct a model. The performance of calibration plots, ROC curves, and decision curve analysis indicated that the model had satisfactory predictive power for 72-h mortality after admission of patients with polytrauma. Moreover, we developed a nomogram for visualization and a web-based calculator for convenient application (https://songandwen.shinyapps.io/DynNomapp/). Conclusions A convenient web-based calculator was constructed to robustly estimate the risk of death in patients with polytrauma within 72 h after admission, which may aid in further rationalization of clinical decision-making and accurate individual treatment.
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Affiliation(s)
- Song Chen
- Department of Orthopaedic Trauma, East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Meiyun Liu
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Di Feng
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xin Lv
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
- Xin Lv
| | - Juan Wei
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
- *Correspondence: Juan Wei
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Sugimoto M, Takayama W, Murata K, Otomo Y. The impact of lactate clearance on outcomes according to infection sites in patients with sepsis: a retrospective observational study. Sci Rep 2021; 11:22394. [PMID: 34789801 PMCID: PMC8599851 DOI: 10.1038/s41598-021-01856-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 11/01/2021] [Indexed: 01/20/2023] Open
Abstract
Whether lactate clearance (LC) influences outcomes differently depending on the infection site in sepsis cases is not fully elucidated. Herein, we analyzed LC's clinical utility as a predictor of patient outcomes according to infection site. This retrospective study, conducted at two tertiary emergency critical care medical centers in Japan, included patients with sepsis or septic shock. The associations between infection site (lungs vs. other organs) and in-hospital mortality and ventilator-free days (VFDs) were evaluated using univariable and multivariate analyses. We assessed LC's ability to predict in-hospital mortality using the area under the receiver operating characteristic curve. Among 369 patients with sepsis, infection sites were as follows: lungs, 186 (50.4%); urinary tract, 45 (12.2%); abdomen, 102 (27.6%); and other, 36 (9.8%). Patients were divided into a pneumonia group or non-pneumonia group depending on their infection site. The pneumonia group displayed a higher in-hospital mortality than the non-pneumonia group (24.2% vs. 15.8%, p = 0.051). In the multivariate analysis, lower LC was associated with higher in-hospital mortality [adjusted odds ratio (AOR), 0.97; 95% confidence interval (CI) 0.96-0.98; p < 0.001] and fewer VFD [adjusted difference p value (AD), - 1.23; 95% CI - 2.42 to - 0.09; p = 0.025] in the non-pneumonia group. Conversely, LC did not affect in-hospital mortality (AOR 0.99; 95% CI 0.99-1.00; p = 0.134) and VFD (AD - 0.08; 95% CI - 2.06 to 1.91; p = 0.854) in the pneumonia group. Given the differences in the impact of LC on outcomes between the pneumonia and non-pneumonia groups, this study suggests that optimal treatment strategies might improve outcomes. Further studies are warranted to validate our results and develop optimal therapeutic strategies for sepsis patients.
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Affiliation(s)
- Momoko Sugimoto
- Department of Emergency and Disaster Medicine, Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-0034, Japan
| | - Wataru Takayama
- Department of Emergency and Disaster Medicine, Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-0034, Japan.
| | - Kiyoshi Murata
- The Shock Trauma and Emergency Medical Center, Matsudo City General Hospital, 933-1 Sendabori, Matsudo, Chiba, Japan
| | - Yasuhiro Otomo
- Department of Emergency and Disaster Medicine, Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-0034, Japan
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10
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Yang JQ, Guo XS, Ran P, Hu XM, Tan N. The relationship between pre-procedural elevated arterial lactate and contrast-induced nephropathy following primary percutaneous coronary intervention. J Thorac Dis 2021; 13:5467-5476. [PMID: 34659813 PMCID: PMC8482345 DOI: 10.21037/jtd-21-1153] [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: 07/01/2021] [Accepted: 08/05/2021] [Indexed: 01/01/2023]
Abstract
Background Risk stratification has been one of the main steps in preventing contrast-induced nephropathy (CIN), which is a common complication after percutaneous coronary intervention (PCI). Elevated arterial lactate is a biomarker indicating severe disease condition and post-intervention complications. The relationship between lactate and CIN has not been established. This study is performed to investigate the relationship between elevated arterial lactate level and contrast-induced nephropathy (CIN). Methods Patients diagnosed with ST-segment elevated myocardial infarction (STEMI) were prospectively enrolled, with lactate measured within 0.5–1 hours before primary percutaneous coronary intervention (PCI). Patients with cardiopulmonary resuscitation, any forms of severe anaerobic condition, or end-stage renal disease undergoing dialysis were excluded. CIN was defined as an increase in serum creatinine ≥0.5 mg/dL or 25% within 72 hours after PCI. The Mehran Risk Score (MRS) is widely regarded as a classic risk model for CIN and the risk factors of MRS were applied in our multivariate regression analysis. Results Of the 227 enrolled patients, 47 (20.7%) developed CIN according to the definition. The mean lactate level was higher in the CIN group than in the non-CIN group (2.68±2.27 vs. 1.74±1.94, P<0.001). The arterial lactate level ≥2.0 mmol/L had 57.5% sensitivity and 75.6% specificity in predicting CIN. The performance of the lactate level in discriminating CIN was similar to that of the MRS (AUClac =0.707 vs. AUCMRS =0.697, P=0.86). After adjusting for other risk factors, lactate ≥2.0 mmol/L still significantly predicted CIN (odds ratio =3.77, 95% CI, 1.77–7.99, P=0.001). Conclusions An arterial lactate level of ≥2.0 mmol/L is associated with CIN in STEMI patients after primary PCI.
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Affiliation(s)
- Jun-Qing Yang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.,Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xiao-Sheng Guo
- Department of Intensive Care Unit, Zhuhai Golden Bay Center Hospital, Guangdong Provincial People's Hospital Zhuhai Hospital, Zhuhai, China
| | - Peng Ran
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xiang-Ming Hu
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.,Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ning Tan
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.,Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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11
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Weinberger J, Klompas M, Rhee C. What Is the Utility of Measuring Lactate Levels in Patients with Sepsis and Septic Shock? Semin Respir Crit Care Med 2021; 42:650-661. [PMID: 34544182 DOI: 10.1055/s-0041-1733915] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Elevations in blood lactate concentrations have been studied in sepsis and other disease states for decades and are well known to be associated with increased mortality. Many studies have also demonstrated the prognostic accuracy of serial lactate levels, and some have suggested that lactate clearance may be a useful therapeutic target for resuscitation. Lactate measurements have therefore gained an increasingly prominent role in sepsis definitions, screening protocols, management guidelines, and quality measures over the past two decades. The heavy emphasis on lactate monitoring, however, has also generated controversy and concerns. Lactate is not specific to infection and its frequent use for sepsis screening and diagnosis may therefore trigger unnecessary broad-spectrum antibiotic use in some patients. Because hyperlactatemia does not always reflect fluid-responsive hypoperfusion, titrating resuscitation to lactate clearance can also lead to unnecessary fluid and volume overload. More broadly, there is a lack of high-quality evidence demonstrating that initial and serial lactate monitoring leads to better patient-centered outcomes. Indeed, a recent randomized controlled trial comparing resuscitation strategies based on lactate clearance versus normalizing capillary refill time showed no benefit and potential harm with lactate-guided therapy. In this article, we review the basic pathobiology of lactate metabolism and delineate why the traditional paradigm that hyperlactatemia reflects tissue hypoxia is overly simplistic and incomplete. We then review the evidence behind the diagnostic, prognostic, and therapeutic uses of lactate monitoring and place this in the context of evolving sepsis diagnosis and management guidelines.
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Affiliation(s)
- Jeremy Weinberger
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.,Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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12
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Saint-Pierre LM, Hopper K, Epstein SE. Retrospective evaluation of the prognostic utility of plasma lactate concentration and serial lactate measurements in dogs and cats presented to the emergency room (January 2012 - December 2016): 4863 cases. J Vet Emerg Crit Care (San Antonio) 2021; 32:42-49. [PMID: 34343401 DOI: 10.1111/vec.13106] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 03/24/2020] [Accepted: 03/29/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the prognostic significance of plasma lactate concentration, plasma lactate clearance, and delta lactate in dogs and cats presented to an emergency room (ER). DESIGN Retrospective study. SETTING University teaching hospital. ANIMALS A total of 8,321 animals with a plasma lactate concentration measured with 4,863 presenting to the ER and 1,529 dogs and 444 cats having a measurement within 4 hours of admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Plasma lactate concentration of dogs and cats presented to a university teaching hospital was retrospectively evaluated. Of dogs and cats with a plasma lactate concentration measured within 4 hours of admission to the ER, hyperlactatemia was common, and the prevalence of hyperlactatemia for dogs 78% (361/462) and cats 67% (78/116) was highest when evaluated within the first 30 minutes following admission. The distribution of patient's plasma lactate concentration was significantly higher in non-survivors compared to survivors at all time points evaluated (P < 0.001). Both lactate clearance (P = 0.010) and delta lactate (P = 0.013) were significantly different between survivors and nonsurvivors. A delta lactate > 4.5 mmol/L was 100% (95% CI: 95 to 100%) specific for nonsurvival in patients with hyperlactatemia measured within 1 hour of admission to the ER. The most common cause of hyperlactatemia was shock in dogs (24%) and urinary tract diseases in cats (22%). Shock was associated with the highest mortality rate in both dogs (61%) and cats (77%). Hyperlactatemia was significantly associated with increased mortality for dogs with shock (P = 0.001), respiratory diseases (P = 0.022), diabetes mellitus (P = 0.018), and liver dysfunction (P = 0.006). CONCLUSIONS Hyperlactatemia was associated with mortality in both dogs and cats when measured at any time point in the 4 hours following admission to the ER. Serial lactate measurement may also be a valuable tool to guide clinical management decisions.
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Affiliation(s)
- Laurence M Saint-Pierre
- Veterinary Medical Teaching Hospital, University of California Davis, Davis, California, USA
| | - Kate Hopper
- Department of Surgical and Radiological Sciences, University of California Davis, Davis, California, USA
| | - Steven E Epstein
- Department of Surgical and Radiological Sciences, University of California Davis, Davis, California, USA
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13
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Qi J, Bao L, Yang P, Chen D. Comparison of base excess, lactate and pH predicting 72-h mortality of multiple trauma. BMC Emerg Med 2021; 21:80. [PMID: 34233612 PMCID: PMC8262006 DOI: 10.1186/s12873-021-00465-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 06/09/2021] [Indexed: 11/18/2022] Open
Abstract
Objective To compare the predictive values of base excess (BE), lactate and pH of admission arterial blood gas for 72-h mortality in patients with multiple trauma. Methods This was a secondary analysis based on a publicly shared trauma dataset from the Dryad database, which provided the clinical data of 3669 multiple trauma patients with ISS > = 16. The records of BE, lactate, pH and 72-h prognosis data without missing values were selected from this dataset and 2441 individuals were enrolled in the study. Logistic regression model was performed to calculate the odds ratios (ORs) of variables. Area under the curve (AUC) of receiver operating curve (ROC) was utilized to evaluate the predictive value of predictors for 72 h in-hospital mortality. Pairwise comparison of AUCs was performed using the Delong’s test. Results The statistically significant correlations were observed between BE and lactate (r = − 0.5861, p < 0.05), lactate and pH (r = − 0.5039, p < 0.05), and BE and pH (r = − 0.7433, p < 0.05). The adjusted ORs of BE, lactate and pH for 72-h mortality with the adjustment for factors including gender, age, ISS category were 0.872 (95%CI: 0.854–0.890), 1.353 (95%CI: 1.296–1.413) and 0.007 (95%CI: 0.003–0.016), respectively. The AUCs of BE, lactate and pH were 0.693 (95%CI: 0.675–0.712), 0.715 (95%CI: 0.697–0.733), 0.670 (95%CI: 0.651–0.689), respectively. Conclusions There are significant correlations between BE, lactate and pH of the admission blood gas, all of them are independent predictors of 72-h mortality for multiple trauma. Lactate may have the best predictive value, followed by BE, and finally pH.
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Affiliation(s)
- Junfang Qi
- Division of Emergency Medicine, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Long Bao
- Division of Emergency Medicine, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Peng Yang
- Division of Emergency Medicine, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Du Chen
- Division of Critical Care Medicine, the First Affiliated Hospital of Soochow University, Suzhou, China.
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14
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Dror N, Weidling J, White S, Ortenzio F, Shreim S, Keating MT, Pham H, Radom-Aizik S, Botvinick E. Clinical evaluation of a novel subcutaneous lactate monitor. J Clin Monit Comput 2021; 36:537-543. [PMID: 33837904 PMCID: PMC8536260 DOI: 10.1007/s10877-021-00685-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 03/02/2021] [Indexed: 01/09/2023]
Abstract
Lactate levels are commonly used as an indirect measure to assess metabolic stress in clinical conditions like sepsis. Dynamic lactate measurements are recommended to assess and guide treatment in patients with shock and other critical care conditions. A minimally invasive, continuous lactate monitor has potential to improve clinical decisions and patient care. The purpose of the study was to evaluate continuous lactate measurements of a novel enzymatic Continuous Lactate Monitor (CLM) developed in our laboratory. Lactate levels were monitored during incremental cycling exercise challenges as a tool for hyperlactatemia. Six healthy individuals 18–45 y/o (4 males, 2 females) participated in the study. CLM devices were inserted subcutaneously in the postero-lateral trunk below the renal angle, one hour before the exercise challenge. Each exercise challenge consisted of a 3 to 12-min warm up period, followed by up to 7, 4-min incremental workload bouts separated by rest intervals. Continuous lactate measurements obtained from CLM were compared with commercial lactate analyzer (Abbott iSTAT) measurements of venous blood (plasma) drawn from the antecubital vein. Blood was drawn at up to 25 time points spanning the duration of before exercise, during exercise, and up to 120 min post exercise. Area under the curve (AUC), and delay time were calculated to compare the CLM readings with plasma lactate concentration. Average plasma lactate concentration increased from 1.02 to 16.21 mM. Ratio of AUC derived from CLM to plasma lactate was 1.025 (0.990–1.058). Average dynamic delay time of CLM to venous plasma lactate was 5.22 min (2.87–10.35). Insertion sites examined 48 h after CLM removal did not show signs of side effects and none required medical attention upon examination. The newly developed CLM has shown to be a promising tool to continuously measure lactate concentration in a minimally invasive fashion. Results indicate the CLM can provide needed trends in lactate over time. Such a device may be used in the future to improve treatment in clinical conditions such as sepsis.
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Affiliation(s)
- Nitsan Dror
- Pediatric Exercise and Genomics Research Center, Department of Pediatrics, School of Medicine, University of California Irvine, Irvine, USA.,Pediatric Department, Meir Medical Center, Child Health and Sports Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - John Weidling
- Beckman Laser Institute and Medical Clinic, University of California Irvine, Irvine, USA
| | - Sean White
- Beckman Laser Institute and Medical Clinic, University of California Irvine, Irvine, USA
| | - Francesca Ortenzio
- Department of Dermatology, University of California Irvine Health, Irvine, USA
| | - Samir Shreim
- Beckman Laser Institute and Medical Clinic, University of California Irvine, Irvine, USA
| | - Mark T Keating
- Beckman Laser Institute and Medical Clinic, University of California Irvine, Irvine, USA
| | - Hoang Pham
- Pediatric Exercise and Genomics Research Center, Department of Pediatrics, School of Medicine, University of California Irvine, Irvine, USA
| | - Shlomit Radom-Aizik
- Pediatric Exercise and Genomics Research Center, Department of Pediatrics, School of Medicine, University of California Irvine, Irvine, USA
| | - Elliot Botvinick
- Beckman Laser Institute and Medical Clinic, University of California Irvine, Irvine, USA. .,Edwards Lifesciences Center for Advanced Cardiovascular Technology, University of California Irvine, Irvine, USA.
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15
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Coggins AR, Vivekanandamoorthy N, Byth K, Aleemullah T, Selvendran ST, Watkins RJ, Shetty AL, Devjak L, Hsu JM. Utility of venous blood gases for the assessment of traumatic shock: a prospective observational study. Emerg Med J 2021; 38:711-717. [PMID: 33789938 DOI: 10.1136/emermed-2020-209751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 03/10/2021] [Accepted: 03/12/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND ABG samples are often obtained in trauma patients to assess shock severity. Venous blood gas (VBG) sampling, which is less invasive, has been widely used to assess other forms of shock. The study aim was to determine the agreement between VBG and ABG measurements in trauma. METHODS Patients were enrolled at an Australian trauma centre between October 2016 and October 2018. Bland-Altman limits of agreement (LOA) between paired blood gas samples taken <30 min apart were used to quantify the extent of agreement. The impact of using only VBG measurements was considered using an a priori plan. Cases where venous sampling failed to detect 'concerning levels' were flagged using evidence-based cut-offs: pH ≤7.2, base deficit (BD) ≤-6, bicarbonate <21 and lactate ≥4. Case summaries of these patients were assessed by independent trauma clinicians as to whether an ABG would change expected management. RESULTS During the study period 176 major trauma patients had valid paired blood gas samples available for analysis. The median time difference between paired measurements was 11 min (IQR 6-17). There was a predominance of men (81.8%) and blunt trauma (92.0%). Median Injury Severity Score was 13 (range 1-75) and inpatient mortality was 6.3%. Mean difference (ABG-VBG) and LOA between paired arterial and venous measurements were 0.036 (LOA -0.048 to 0.120) for pH, -1.27 mmol/L (LOA -4.35 to 1.81) for BD, -0.64 mmol/L (LOA -1.86 to 0.57) for lactate and -1.97 mmol/L (LOA -5.49 to 1.55) for bicarbonate. Independent assessment of the VBG 'false negative' cases (n=20) suggested an ABG would change circulatory management in two cases. CONCLUSIONS In trauma patients VBG and ABG parameters displayed suboptimal agreement. However, in cases flagged as VBG 'false negative' independent review indicated that the availability of an ABG was unlikely to change management.
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Affiliation(s)
- Andrew R Coggins
- Emergency Medicine, Westmead Hospital, Westmead, New South Wales, Australia .,Discipline of Emergency Medicine, The University of Sydney Westmead Clinical School, Sydney, New South Wales, Australia
| | | | - Karen Byth
- Biostatistics Department, NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Tabish Aleemullah
- Department of Trauma, Westmead Hospital, Westmead, New South Wales, Australia
| | - Selwyn T Selvendran
- Department of Trauma, Westmead Hospital, Westmead, New South Wales, Australia
| | - Rachel J Watkins
- Department of Trauma, Westmead Hospital, Westmead, New South Wales, Australia
| | - Amith L Shetty
- Discipline of Emergency Medicine, The University of Sydney Westmead Clinical School, Sydney, New South Wales, Australia
| | - Lorraine Devjak
- Nursing Resources, Westmead Hospital, Westmead, New South Wales, Australia
| | - Jeremy M Hsu
- Department of Trauma, Westmead Hospital, Westmead, New South Wales, Australia.,Discipline of Surgery, The University of Sydney Westmead Clinical School, Sydney, New South Wales, Australia
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16
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Abstract
The basis of all metabolic processes in the human body is the production and metabolism of carriers of energy. Lactate is the end-product of anaerobic glycolysis. Lactate can serve as a substrate for gluconeogenesis and as an oxidation substrate. Hyperlactatemia can be detected as the result of a multitude of acute events (e.g. shock, sepsis, cardiac arrest, trauma, seizure, ischemia, diabetic ketoacidosis, thiamine deficiency, liver failure and intoxication). Hyperlactatemia can be associated with increased mortality, therefore in emergency medicine the search for the cause of hyperlactatemia is just as important as an effective causal treatment. Repetitive measurements of lactate are components of several treatment algorithms as observation of the dynamic development of blood lactate concentrations can help to make a better assessment of the acute medical condition of the patient and to evaluate the effectiveness of the measures undertaken.
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17
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Spiegel R, Gordon D, Marik PE. The origins of the Lacto-Bolo reflex: the mythology of lactate in sepsis. J Thorac Dis 2020; 12:S48-S53. [PMID: 32148925 DOI: 10.21037/jtd.2019.11.48] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The use of lactate as a marker of the severity of circulatory shock was popularized by Dr. Weil in the 1970's. Dr. Weil promoted the idea that blood lactate concentration increased in circulatory shock due to anaerobic metabolism following decreased oxygen delivery. This concept becomes entrenched with 1992 ACCP/SCCM consensus conference definition of sepsis. Since then, the central role of lactate in the definition and management of septic shock has only been expanded and become more ingrained. This review will discuss the wisdom of such an approach, an updated model describing the origins of hyperlactatemia in sepsis, and how such improvements in our knowledge of the underlying physiology should change our approach to resuscitation in patients presenting with septic shock.
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Affiliation(s)
- Rory Spiegel
- Department of Critical Care and Department of Emergency Medicine, Georgetown University Medstar Washington Hospital Center, Washington, DC, USA
| | - David Gordon
- Department of Pulmonary and Critical Care, University of Maryland Medical Center, Baltimore, MD, USA
| | - Paul E Marik
- Department of Internal Medicine, Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
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18
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Verhaeghe M, Hachimi-Idrissi S. Blood lactate and lactate kinetics as treatment and prognosis markers for tissue hypoperfusion. Acta Clin Belg 2020; 75:1-8. [PMID: 30591001 DOI: 10.1080/17843286.2018.1560612] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Objective: Blood lactate concentration (L) and lactate kinetic (LK) over time might be a helpful marker of the shock severity. The purpose of this study is to analyze whether the L and LK could correlate with the outcome and the therapy of patients with different types of shock.Methods: Design: A 3.5-year retrospective observational study. Patients: Eighteen years of age or older, diagnosed with shock were included. Arterial L measurements were performed upon admission and approximatively 3 and 6 h later. The evolution of lactate over this period of time was correlated with the outcome and therapy. Interventions: Univariate and multivariable statistical tests were performed to examine the relation between the initial L/LK and the in-hospital mortality, total mortality, length of stay (LOS), the LOS at the intensive care unit and the administered therapy. The optimal cut-off point of the LK over time to predict the mortality was calculated.Results: The initial L and the 6 h LK were significantly associated with the outcome. The higher the initial L and lower the LK, the higher the risk of mortality in the hospital or within 6 months. Moreover, the higher the initial L and lower the 6 h LK, the longer was the LOS. A relation between the initial L/LK and the required therapy was found. The optimal cut-off for the 6-h LK is 38.1%. Patients with a 6 h LK >38.1% had a significantly higher chance of survival.Conclusions: A significant relationship between the L/6-h LK and the outcome and treatment was found. The optimal survival cut-off point of 6 h LK in our study was 38.1%.
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Affiliation(s)
- Marzia Verhaeghe
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Saïd Hachimi-Idrissi
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
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19
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Innocenti F, Meo F, Giacomelli I, Tozzi C, Ralli ML, Donnini C, Tassinari I, Caldi F, Zanobetti M, Pini R. Prognostic value of serial lactate levels in septic patients with and without shock. Intern Emerg Med 2019; 14:1321-1330. [PMID: 31555948 DOI: 10.1007/s11739-019-02196-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 09/11/2019] [Indexed: 11/27/2022]
Abstract
To analyze the prognostic value of lactate levels for day-7 and in-hospital mortality, in septic patients with and without shock. In the period November 2011-December 2016, we enrolled 268 patients, admitted to our High-Dependency Unit with a diagnosis of sepsis. Lactate dosage was performed at ED-HDU admission (T0), after 2 h (T2), 6 h (T6) and 24 h (T24); lactate clearance was calculated at T2 and T6 [T2: ((LAC T0-LAC T2/LAC T0)*100)]; T6: [(LAC T0-LAC T6/LAC T0)*100]. The end-points were day-7 and in-hospital mortality. At every evaluation, the lactate level was higher in patients with shock than in those without (T0 3.8 ± 3.8 vs 2.4 ± 2.1; T6 2.9 ± 3.2 vs 1.6 ± 1.1; T24 3.0 ± 4.4 vs 1.4 ± 0.9 meq/L, all p < 0.001). Among patients with shock, an analysis for repeated measures confirmed a more marked lactate level reduction in survivors compared with non-survivors, both by day-7 and in-hospital mortality (p = 0.057 and p = 0.006). A Kaplan-MeIer analysis confirmed a significantly better day-7 survival in patients with T6 (with shock 86% vs 70%; without shock 93% vs 82, all p < 0.05) and T24 (with shock 86% vs 70%; without shock 93% vs 82, all p < 0.05) lactate ≤ 2 meq/L, compared with patients with higher levels. A T6 lactate clearance > 10% was more frequent among in-hospital survivors in the whole study population (57% vs 39%) and in patients with shock (74% vs 46%, all p < 0.05). Higher lactate levels and decreased clearance were associated with an increased short-term and intermediate-term mortality regardless of the presence of shock.
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Affiliation(s)
- Francesca Innocenti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Francesca Innocenti, Lg. Brambilla 3, 50134, Firenze, Italy.
| | - Federico Meo
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Francesca Innocenti, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Irene Giacomelli
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Francesca Innocenti, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Camilla Tozzi
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Francesca Innocenti, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Maria Luisa Ralli
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Francesca Innocenti, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Chiara Donnini
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Francesca Innocenti, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Irene Tassinari
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Francesca Innocenti, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Francesca Caldi
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Francesca Innocenti, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Maurizio Zanobetti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Francesca Innocenti, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Riccardo Pini
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Francesca Innocenti, Lg. Brambilla 3, 50134, Firenze, Italy
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20
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Lactate Level Versus Lactate Clearance for Predicting Mortality in Patients With Septic Shock Defined by Sepsis-3. Crit Care Med 2019; 46:e489-e495. [PMID: 29432347 DOI: 10.1097/ccm.0000000000003030] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES This study aimed to compare the prognostic value of lactate level and lactate clearance at 6 hours after septic shock recognition. And, we performed it to determine lactate kinetics in the Sepsis-3 defined septic shock. DESIGN This retrospective study was performed from a prospective septic shock registry. SETTINGS This study was performed at single urban tertiary center. And, all patients were treated with protocol-driven resuscitation bundle therapy between 2010 and 2016. PATIENTS We included septic shock patients who met the Sepsis-3 definition, which involves lactate levels greater than or equal to 2 mmol/L and vasopressor use. INTERVENTIONS Serum lactate levels were measured at initial and 6 hours from septic shock recognition. MEASUREMENTS AND MAIN RESULTS Lactate clearance was calculated as ([initial lactate - 6-hr lactate]/initial lactate) × 100. The prognostic value of measured lactate levels and lactate clearance for 28-day mortality was analyzed and compared with that of subsequent lactate levels greater than or equal to 2 mmol/L, greater than or equal to 3 mmol/L, and greater than or equal to 4 mmol/L and less than 10%, less than 20%, and less than 30% lactate clearance. A total of 1,060 septic shock patients by Sepsis-3, 265 patients died (28-d mortality: 25%). In survivor, groups had lower median 6-hour lactate level and higher lactate clearance than nonsurvivors (2.5 vs 4.6 mmol/L and 35.4% vs 14.8%; p < 0.01). Both lactate and lactate clearance were associated with mortality after adjusting for confounders (odd ratio, 1.27 [95% CI, 1.21-1.34] and 0.992 [95% CI, 0.989-0.995]), but lactate had a significantly higher prognostic value than lactate clearance (area under the curve, 0.70 vs 0.65; p < 0.01). The prognostic value of subsequent lactate levels (≥ 2, ≥ 3, and ≥ 4 mmol/L) and lactate clearances (< 10%, < 20%, and < 30%) was not significantly differed. However, lactate levels of greater than or equal to 2 mmol/L had the greatest sensitivity (85.3%). CONCLUSIONS Our findings indicate lactate and lactate clearance are both useful targets in patients with septic shock defined by Sepsis-3. Serum lactate level at 6-hour can be an easier and more effective tool for prognosis of septic shock patients who were treated with protocol-driven resuscitation bundle therapy.
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21
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Wardi G, Brice J, Correia M, Liu D, Self M, Tainter C. Demystifying Lactate in the Emergency Department. Ann Emerg Med 2019; 75:287-298. [PMID: 31474479 DOI: 10.1016/j.annemergmed.2019.06.027] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 06/26/2019] [Accepted: 06/26/2019] [Indexed: 01/13/2023]
Abstract
The role of lactic acid and its conjugate base, lactate, has evolved during the past decade in the care of patients in the emergency department (ED). A recent national sepsis quality measure has led to increased use of serum lactate in the ED, but many causes for hyperlactatemia exist outside of sepsis. We provide a review of the biology of lactate production and metabolism, the many causes of hyperlactatemia, and evidence on its use as a marker in prognosis and resuscitation. Additionally, we review the evolving role of lactate in sepsis care. We provide recommendations to aid lactate interpretation in the ED and highlight areas for future research.
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Affiliation(s)
- Gabriel Wardi
- Department of Emergency Medicine, University of California at San Diego, San Diego, CA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California at San Diego, San Diego, CA.
| | - Jessica Brice
- Department of Emergency Medicine, University of California at San Diego, San Diego, CA
| | - Matthew Correia
- Department of Emergency Medicine, University of California at San Diego, San Diego, CA
| | - Dennis Liu
- Department of Emergency Medicine, University of California at San Diego, San Diego, CA
| | - Michael Self
- Department of Emergency Medicine, University of California at San Diego, San Diego, CA
| | - Christopher Tainter
- Department of Emergency Medicine, University of California at San Diego, San Diego, CA; Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, University of California at San Diego, San Diego, CA
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22
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Nazir M, Wani W, Dar SA, Mir IH, Charoo BA, Ahmad QI, Wajid S. Lactate clearance prognosticates outcome in pediatric septic shock during first 24 h of intensive care unit admission. J Intensive Care Soc 2019; 20:290-298. [PMID: 31695733 DOI: 10.1177/1751143719855202] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
This study was undertaken to examine the clinical utility of lactate clearance as an indicator of mortality in pediatric septic shock, and to compare the performance of lactate clearance at 6, 12, and 24 h for predicting in-hospital and 60-day mortality. Pediatric patients with septic shock were prospectively studied. Vital signs, laboratory values, Pediatric Risk of Mortality Score, and pediatric logistic organ dysfunction score were obtained at presentation (hour 0), hour 6, hour 24 and over the first 72 h of hospitalization. Lactate clearance was obtained at 6, 12, and 24 h of hospital admission. Therapy received, outcome parameters of mortality, and duration of hospitalization were recorded. The primary outcome variable of 60-day mortality rate was 31.25%. Only lactate clearance at 6 and 24 h was significantly associated with mortality, with odds of 0.97 (95% CI, 0.951-981; p < 0.001) and 0.975 (95% CI, 0.964-0.986; p < 0.001), respectively. Approximately there was a 24% decrease in likelihood of mortality for each 10% increase in lactate clearance at 24 h. At a threshold value of 10% 6-h lactate clearance had a sensitivity of 0.948 and specificity of 0.571, while at a threshold of 20% 24-h lactate clearance had a sensitivity of 0.922 and specificity of 0.629. The comparison of clearance at 6 and 24 h using receiver operating characteristic showed that former was "fair" (area under the curve = 0.753) and later was "good" (area under the curve = 0.81) in predicting mortality in pediatric septic shock. Conclusion We concluded that optimal lactate clearance in pediatric septic shock both during the early presentation and after the initial "golden hours" is associated with lower in-hospital and 60-day mortality. Further, 24-h lactate clearance appears superior to 6 h lactate clearance in predicting mortality in such patients.
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Affiliation(s)
- Mudasir Nazir
- Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, India
| | - Wasim Wani
- Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, India
| | - Sheeraz Ahmad Dar
- Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, India
| | - Inamul-Haq Mir
- Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, India
| | - Bashir Ahmad Charoo
- Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, India
| | - Qazi Iqbal Ahmad
- Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, India
| | - Syed Wajid
- Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, India
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Gao X, Cao W, Li P. Pcv-aCO 2/Ca-cvO 2 Combined With Arterial Lactate Clearance Rate as Early Resuscitation Goals in Septic Shock. Am J Med Sci 2019; 358:182-190. [PMID: 31229247 DOI: 10.1016/j.amjms.2019.04.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 04/28/2019] [Accepted: 04/29/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND We aimed to investigate the prognostic significance of central venous-arterial carbon dioxide tension to arterial-central venous oxygen content ratio (Pcv-aCO2/Ca-cvO2) combined with arterial lactate clearance rate (LCR) as early resuscitation goals in septic shock. MATERIALS AND METHODS We enrolled 145 septic shock patients admitted to our department from March 2013 to May 2017 in this study. They all received an initial resuscitation therapy according to the Surviving Sepsis Campaign guideline, and were classified into 4 groups according to Pcv-aCO2/Ca-cvO2 and LCR at 6 hours after resuscitation (T6): Group A: Pcv-aCO2/Ca-cvO2 > 1.8, LCR < 30%; Group B: Pcv-aCO2/Ca-cvO2 > 1.8, LCR ≥ 30%; Group C: Pcv-aCO2/Ca-cvO2 ≤ 1.8, LCR < 30% and Group D: Pcv-aCO2/Ca-cvO2 ≤ 1.8, LCR ≥ 30%. General demographics, hemodynamic parameters, metabolic parameters, Acute Physiology and Chronic Health Evaluation II scores, Sequential Organ Failure Assessment scores, length of intensive care unit stay and 28-day mortality were compared among groups. RESULTS Group D had the lowest Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment score at day 3, the shortest intensive care unit stay and the lowest 28-day mortality. Kaplan-Meier survival curves up to day 28 showed group D had the longest median survival time. Pcv-aCO2/Ca-cvO2 and LCR at T6 were independent predictors of 28-day mortality. The area under ROC curve for Pcv-aCO2/Ca-cvO2 combined with LCR was significantly greater than either Pcv-aCO2/Ca-cvO2 or LCR alone (both P < 0.05). CONCLUSIONS Combination of Pcv-aCO2/Ca-cvO2 ratio and LCR is better than either alone to predict the adverse outcomes in septic shock, and may provide useful information for assessing the adequacy of resuscitation in early-stage septic shock.
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Affiliation(s)
- Xuehua Gao
- Department of Critical Care Medicine, Lanzhou University Second Hospital, Lanzhou, Gansu Province, China
| | - Wen Cao
- Department of Critical Care Medicine, Lanzhou University Second Hospital, Lanzhou, Gansu Province, China
| | - Peijie Li
- Department of Critical Care Medicine, Lanzhou University Second Hospital, Lanzhou, Gansu Province, China.
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Gouëzel C, Lorne E, Bonnet V, Fradin S, Saplacan V, Gérard JL, Hanouz JL, Fellahi JL, Fischer MO. Assessment of changes in lactate concentration with intravascular microdialysis during high-risk cardiac surgery using the trend interchangeability method. Br J Anaesth 2019; 119:1110-1117. [PMID: 29028910 DOI: 10.1093/bja/aex338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2017] [Indexed: 01/10/2023] Open
Abstract
Background Blood lactate is a strong predictor of mortality, and repeated blood lactate assays are recommended during surgery in high-risk patients. We hypothesized that the use of intravascular microdialysis incorporated in a central venous catheter would be interchangeable with the reference blood gas technique to monitor changes in blood lactate. Methods Microdialysis and central venous blood lactate measurements were recorded simultaneously in high-risk cardiac surgical patients. The correlation between absolute values was determined by linear regression, and the Bland-Altman test for repeated measurements was used to compare bias, precision, and limits of agreement. Changes in lactate measurements were evaluated with a four-quadrant plot and trend interchangeability method (TIM). Results In the 23 patients analysed, the central venous catheter was used as part of standard care, with no complications. The correlation coefficient for absolute values ( n =104) was 0.96 ( P <0.0001). The bias, precision, and limits of agreement were -0.19, 0.51, and -1.20 to 0.82 mmol litre -1 , respectively. The concordance rate for changes in blood lactate measurements ( n =80) was 94% with the four-quadrant plot. In contrast, the TIM showed that 23 (29) changes in lactate measurements were not interpretable, and among the remaining 57 (71) interpretable changes, 18 (32) were interchangeable, 8 (14) were in the grey zone, and 31 (54) were not interchangeable. Conclusions Microdialysis with a central venous catheter appears to provide reliable absolute blood lactate values. Although changes in blood lactate measurements showed an excellent concordance rate, changes between the two methods were poorly interchangeable with the TIM. Clinical trial registration NCT02296593.
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Affiliation(s)
- C Gouëzel
- Department of Anaesthesia and Intensive Care Medicine, Caen University Hospital, Avenue de la Côte de Nacre, CS 30001, F-14000 Caen, France
| | - E Lorne
- Anaesthesiology and Critical Care Department, Amiens University Medical Centre, avenue René Laennec, F-80054 Amiens, France.,INSERM U1088, Jules Verne University of Picardy, Centre Universitaire de Recherche en Santé (CURS), Chemin du Thil, F-80025 Amiens cedex, France
| | - V Bonnet
- Department of Anaesthesia and Intensive Care Medicine, Caen University Hospital, Avenue de la Côte de Nacre, CS 30001, F-14000 Caen, France
| | - S Fradin
- Department of Biology, Caen University Hospital, Avenue de la Côte de Nacre, CS 30001, F-14000 Caen, France
| | - V Saplacan
- Cardiac Surgery, Caen University Hospital, Avenue de la Côte de Nacre, CS 30001, F-14000 Caen, France
| | - J-L Gérard
- Department of Anaesthesia and Intensive Care Medicine, Caen University Hospital, Avenue de la Côte de Nacre, CS 30001, F-14000 Caen, France
| | - J-L Hanouz
- Department of Anaesthesia and Intensive Care Medicine, Caen University Hospital, Avenue de la Côte de Nacre, CS 30001, F-14000 Caen, France.,EA 4650, Caen Normandy University, Esplanade de la Paix, CS 14 032, F-14000 Caen, France
| | - J-L Fellahi
- Department of Anaesthesia and Intensive Care Medicine, Hôpital cardiologique Louis Pradel, Avenue du Doyen Lepine, F-69 677 Lyon, France.,Faculty of Medicine, University of Lyon 1 Claude Bernard, F-69 008 Lyon, France
| | - M-O Fischer
- Department of Anaesthesia and Intensive Care Medicine, Caen University Hospital, Avenue de la Côte de Nacre, CS 30001, F-14000 Caen, France.,EA 4650, Caen Normandy University, Esplanade de la Paix, CS 14 032, F-14000 Caen, France
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Hashim IA, Mohamed M, Cox A, Fernandez F, Kutscher P. Plasma lactate measurement as an example of encountered gaps between routine clinical laboratory processes and manufactures' sample-handling instructions. Pract Lab Med 2018; 12:e00109. [PMID: 30426060 PMCID: PMC6223191 DOI: 10.1016/j.plabm.2018.e00109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 08/28/2018] [Accepted: 10/17/2018] [Indexed: 11/16/2022] Open
Abstract
Objectives Deviation from manufacturers’ pre-analytical sample handling recommendations necessitates extensive validation studies. This report uses plasma lactate testing, where a recommended 15 min room temperature sample handling limit cannot be met by the clinical laboratory, as an example for studies to bridge the gap with practice. Design and Methods Triplicate blood samples were collected from patients (n = 51) with lactate requests by clinicians and from normal volunteers (n = 50). One tube was transported on ice (4 °C), the others were maintained at room temperature (23 °C). Tubes stored at 4 °C were processed at 30 min from collection. Tubes stored at 23 °C were processed at 15 and at 30 min from collection. Lactate levels were measured using Roche Diagnostics Cobas 6000® analyzer. Results Lactate levels in normal subjects ranged from 0.6 to 3.1 mmol/L (median 1.1). Patient lactate levels ranged from 0.8 to 26.3 mmol/L (median 2.2). Bias in lactate levels following extended storage of samples from both normal subjects and patients ranged from − 1.3 to2.2 and from − 1.0–1.0 mmol/L when stored for 30 min at 23 °C or at 4 °C, respectively. The bias between lactate levels at 30 min at 23 °C and 4 °C was − 1.2 to − 0.5 mmol/L for both populations. Although the bias was not statistically significant for all variables, a clinically significant (>0.2 mmol/L) bias was observed in 28% of normal and 7.0% of patient samples. Conclusion Extending the pre-analytical time to 30 min at 23 °C did not significantly impact clinical utility of lactate measurement in our patient population. Pre-analytical gaps exist between manufacturers’ recommendation and clinical practice. Sample handling time for lactate testing was extended to reflect clinical practice. Normal subjects, often preferred, showed high variability compared to patients. Patient samples must always be included in pre-analytics studies. Doubling handling time at 23 °C did not have significant clinical impact.
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Affiliation(s)
- Ibrahim A Hashim
- Clinical Laboratories, Parkland Health and Hospital System, United States.,Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mishkat Mohamed
- Clinical Laboratories, Parkland Health and Hospital System, United States
| | - Aileen Cox
- Clinical Laboratories, Parkland Health and Hospital System, United States
| | | | - Patricia Kutscher
- Clinical Laboratories, Parkland Health and Hospital System, United States
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26
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Rosenstein PG, Tennent-Brown BS, Hughes D. Clinical use of plasma lactate concentration. Part 2: Prognostic and diagnostic utility and the clinical management of hyperlactatemia. J Vet Emerg Crit Care (San Antonio) 2018. [PMID: 29533517 DOI: 10.1111/vec.12706] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To review the current literature pertaining to the use of lactate as a prognostic indicator and therapeutic guide, the utility of measuring lactate concentrations in body fluids other than blood or plasma, and the clinical management of hyperlactatemia in dogs, cats, and horses. DATA SOURCES Articles were retrieved without date restrictions primarily via PubMed, Scopus, and CAB Abstracts as well as by manual selection. HUMAN AND VETERINARY DATA SYNTHESIS Increased plasma lactate concentrations are associated with increased morbidity and mortality. In populations with high mortality, hyperlactatemia is moderately predictive in identifying nonsurvivors. Importantly, eulactatemia predicts survival better than hyperlactatemia predicts death. Consecutive lactate measurements and calculated relative measures appear to outperform single measurements. The use of lactate as a therapeutic guide has shown promising results in people but is relatively uninvestigated in veterinary species. Increased lactate concentrations in body fluids other than blood should raise the index of suspicion for septic or malignant processes. Management of hyperlactatemia should target the underlying cause. CONCLUSION Lactate is a valuable triage and risk stratification tool that can be used to separate patients into higher and lower risk categories. The utility of lactate concentration as a therapeutic target and the measurement of lactate in body fluids shows promise but requires further research.
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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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27
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Timing of Repeated Lactate Measurement in Patients With Septic Shock at the Emergency Department. Am J Med Sci 2018; 356:97-102. [PMID: 30219168 DOI: 10.1016/j.amjms.2018.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 05/01/2018] [Accepted: 05/03/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND The objective of this study was to evaluate the prognostic value of lactate levels during the first 12 hours after shock development and to identify the optimal timing for repeated lactate measurements in patients with septic shock. METHODS We conducted a retrospective cohort study using a prospective data registry, and enrolled 2,226 consecutive adult patients with septic shock between January 2010 and December 2015. Blood lactate was measured at shock development, and after 2, 4, 6 and 12 hours (T0, T2, T4, T6 and T12) during protocol-driven resuscitation bundle therapy. The prognostic value of lactate levels for 28-day mortality was analyzed using logistic regression and receiver operating characteristic curve analysis. RESULTS A total of 829 patients with septic shock were included in the study, among whom 211 died during the study period. The lactate levels at each time point were associated with increased 28-day mortality, and the lactate level at 6 hours had the greatest prognostic value (area under the curve of T0 = 0.61; T2 = 0.65; T4 = 0.69; T6 = 0.72 and T12 = 0.62, and odds ratio (OR) of T0, 1.17 [95% CI: 1.11-1.23]; T2, 1.23 [95% CI: 1.17-1.30]; T4, 1.30 [95% CI: 1.22-1.38]; T6, 1.33 [95% CI: 1.26-1.42] and T12, 1.24 [95% CI: 1.19-1.30]). Hyperlactatemia over 2mmol/L and 4mmol/L at 6 hours from shock was associated with 4-times higher mortality (≥2mmol/L, OR = 3.89 [95% CI: 2.48-6.09]; ≥4mmol/L, OR = 3.93 [95% CI: 2.83-5.44]). CONCLUSIONS During the first 12 hours following shock development, the optimal time point of repeated blood lactate measurement was 6 hours, which was the greatest prognostic value for mortality.
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Pepper DJ, Jaswal D, Sun J, Welsh J, Natanson C, Eichacker PQ. Evidence Underpinning the Centers for Medicare & Medicaid Services' Severe Sepsis and Septic Shock Management Bundle (SEP-1): A Systematic Review. Ann Intern Med 2018; 168:558-568. [PMID: 29459977 PMCID: PMC11146290 DOI: 10.7326/m17-2947] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This article has been corrected. To see what has changed, please read the Letter to the Editor and the authors' response. The original version (PDF) is appended to this article as a Supplement. Background The Severe Sepsis and Septic Shock Early Management Bundle (SEP-1), the sepsis performance measure introduced in 2015 by the Centers for Medicare & Medicaid Services (CMS), requires the reporting of up to 5 hemodynamic interventions, as many as 141 tasks, and 3 hours to document for a single patient. Purpose To evaluate whether moderate- or high-level evidence shows that use of the 2015 SEP-1 or its hemodynamic interventions improves survival in adults with sepsis. Data Sources PubMed, Embase, Scopus, Web of Science, and ClinicalTrials.gov from inception to 28 November 2017 with no language restrictions. Study Selection Randomized and observational studies of death among adults with sepsis who received versus those who did not receive either the entire SEP-1 bundle or 1 or more SEP-1 hemodynamic interventions, including serial lactate measurements; a fluid infusion of 30 mL/kg of body weight; and assessment of volume status and tissue perfusion with a focused examination, bedside cardiovascular ultrasonography, or fluid responsiveness testing. Data Extraction Two investigators independently extracted study data and assessed each study's risk of bias; 4 authors rated level of evidence by consensus using CMS criteria published in 2013. High- or moderate-level evidence required studies to have no confounders and low risk of bias. Data Synthesis Of 56 563 references, 20 studies (18 reports) met inclusion criteria. One single-center observational study reported lower in-hospital mortality after implementation of the SEP-1 bundle. Sixteen studies (2 randomized and 14 observational) reported increased survival with serial lactate measurements or 30-mL/kg fluid infusions. None of the 17 studies were free of confounders or at low risk of bias. In 3 randomized trials, fluid responsiveness testing did not alter survival. Limitations Few trials, poor-quality and confounded studies, and no studies (with survival outcomes) of the focused examination or bedside cardiovascular ultrasonography. Use of the 2015 version of SEP-1 and 2013 version of CMS evidence criteria, both of which were updated in 2017. Conclusion No high- or moderate-level evidence shows that SEP-1 or its hemodynamic interventions improve survival in adults with sepsis. Primary Funding Source National Institutes of Health. (PROSPERO: CRD42016052716).
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Affiliation(s)
- Dominique J Pepper
- National Institutes of Health, Bethesda, Maryland (D.J.P., D.J., J.S., J.W., C.N., P.Q.E.)
| | - Dharmvir Jaswal
- National Institutes of Health, Bethesda, Maryland (D.J.P., D.J., J.S., J.W., C.N., P.Q.E.)
| | - Junfeng Sun
- National Institutes of Health, Bethesda, Maryland (D.J.P., D.J., J.S., J.W., C.N., P.Q.E.)
| | - Judith Welsh
- National Institutes of Health, Bethesda, Maryland (D.J.P., D.J., J.S., J.W., C.N., P.Q.E.)
| | - Charles Natanson
- National Institutes of Health, Bethesda, Maryland (D.J.P., D.J., J.S., J.W., C.N., P.Q.E.)
| | - Peter Q Eichacker
- National Institutes of Health, Bethesda, Maryland (D.J.P., D.J., J.S., J.W., C.N., P.Q.E.)
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Nouriel JE, Millis SR, Ottolini J, Wilburn JM, Sherwin RL, Paxton JH. Blood pressure variability as an indicator of sepsis severity in adult emergency department patients. Am J Emerg Med 2017; 36:560-566. [PMID: 28967450 DOI: 10.1016/j.ajem.2017.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 09/11/2017] [Accepted: 09/13/2017] [Indexed: 10/18/2022] Open
Abstract
STUDY OBJECTIVE Quantify the correlation between blood pressure variability (BPV) and markers of illness severity: serum lactate (LAC) or Sequential Organ Failure Assessment (SOFA) scores. METHODS We performed a secondary analysis of data from a prospective, observational study evaluating fluid resuscitation on adult, septic, ED patients. Vital signs and fluid infusion volumes were recorded every 15min during the 3h following ED arrival. BPV was assessed via average real variability (ARV): the average of the absolute differences between consecutive BP measurements. ARV was calculated for the time periods before and after 3 fluid infusion milestones: 10-, 20-, and 30-mL/kg total body weight (TBW). Spearman's rho correlation coefficient analysis was utilized. A p-value<0.05 was considered statistically significant. RESULTS Forty patients were included. Mean fluid infusion was 33.7mL/kg TBW (SD 22.1). All patients received fluid infusion≥10mL/kg TBW, 25 patients received fluid infusion>20mL/kg TBW, and 16 patients received fluid infusion>30mL/kg TBW. Mean initial LAC was 4.0mmol/L (SD 3.2). Mean repeat LAC was 3.1mmol/L (SD 3.2), obtained an average of 6.6h (SD 5.3) later. Mean SOFA score was 7.0 (SD 4.4). BPV correlated with both follow-up LAC (r=0.564; p=0.023) and SOFA score (r=0.544; p=0.024) among the cohort that received a fluid infusion>20-mL/kg TBW. CONCLUSION With the finding of a positive correlation between BPV and markers of illness severity (LAC and SOFA scores), this pilot study introduces BPV analysis as a real-time, non-invasive tool for continuous sepsis monitoring in the ED.
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Affiliation(s)
- Jacob E Nouriel
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI, USA.
| | - Scott R Millis
- Department of Physical Medicine and Rehabilitation, Wayne State University School of Medicine, Detroit, MI, USA
| | - Jonathon Ottolini
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - John M Wilburn
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Robert L Sherwin
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - James H Paxton
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI, USA
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Xu LY, Xu D. [Changes in blood oxygen metabolism indices and their clinical significance in children with septic shock]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19:1124-1128. [PMID: 29046213 PMCID: PMC7389280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 07/21/2017] [Indexed: 08/01/2024]
Abstract
The key to the treatment of septic shock is to provide adequate oxygen supply and improve tissue perfusion. Lactate and central venous oxygen saturation (ScvO2) are commonly used as the indices of oxygen metabolism, but tissue hypoxia may still exist even when lactate and ScvO2 are within the normal range. Arteriovenous difference in carbon dioxide partial pressure (CO2 gap) can accurately reflect oxygen delivery when ScvO2 is in the normal range. This article reviews the advantages and shortages of lactate, lactate clearance rate, ScvO2, and CO2 gap in evaluating tissue hypoxia, in order to provide a reference for treatment and severity evaluation of septic shock.
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Affiliation(s)
- Ling-Yang Xu
- Department of Pediatrics, Second Hospital of Lanzhou University, Lanzhou 730000, China.
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31
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Xu LY, Xu D. [Changes in blood oxygen metabolism indices and their clinical significance in children with septic shock]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19:1124-1128. [PMID: 29046213 PMCID: PMC7389280 DOI: 10.7499/j.issn.1008-8830.2017.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 07/21/2017] [Indexed: 06/07/2023]
Abstract
The key to the treatment of septic shock is to provide adequate oxygen supply and improve tissue perfusion. Lactate and central venous oxygen saturation (ScvO2) are commonly used as the indices of oxygen metabolism, but tissue hypoxia may still exist even when lactate and ScvO2 are within the normal range. Arteriovenous difference in carbon dioxide partial pressure (CO2 gap) can accurately reflect oxygen delivery when ScvO2 is in the normal range. This article reviews the advantages and shortages of lactate, lactate clearance rate, ScvO2, and CO2 gap in evaluating tissue hypoxia, in order to provide a reference for treatment and severity evaluation of septic shock.
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Affiliation(s)
- Ling-Yang Xu
- Department of Pediatrics, Second Hospital of Lanzhou University, Lanzhou 730000, China.
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Frenzen FS, Kutschan U, Meiswinkel N, Schulte-Hubbert B, Ewig S, Kolditz M. Admission lactate predicts poor prognosis independently of the CRB/CURB-65 scores in community-acquired pneumonia. Clin Microbiol Infect 2017; 24:306.e1-306.e6. [PMID: 28710027 DOI: 10.1016/j.cmi.2017.07.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 06/06/2017] [Accepted: 07/04/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Community-acquired pneumonia (CAP) is associated with a high risk of respiratory failure or septic organ dysfunction. Lactate is an established early marker of prognosis and sepsis severity, but few data exist in patients with CAP. METHODS We performed a retrospective cohort study of consecutive adult CAP patients without treatment restrictions or direct intensive care unit admission. Lactate was measured as a point-of-care test within the capillary admission blood gas analysis, and its prognostic value was compared to the CRB/CURB-65 criteria by multivariate and receiver operating characteristic (ROC) curve analysis. The primary endpoint was the combination of need for mechanical ventilation, vasopressors, intensive care unit admission or hospital mortality. RESULTS Of 303 included patients, 75 (25%) met the primary endpoint. After ROC analysis, lactate predicted the primary endpoint (area under the curve 0.67) with an optimal cutoff of >1.8 mmol/L. Of the 76 patients with lactate above this threshold, 35 (46%) met the primary endpoint. After multivariate analysis, the predictive value of lactate was independent of the CRB/CURB-65 scores. The addition of lactate >1.8 mmol/L to the CRB/CURB-65 scores resulted in significantly improved area under the curves (0.69 to 0.74, p 0.005 and 0.71 to 0.75, p 0.008 respectively). Fourteen (42%) of 33 and 11 (39%) of 28 patients meeting the endpoint despite presenting with 0 or 1 CRB/CURB-65 criteria had lactate >1.8 mmol/L. CONCLUSIONS Admission lactate levels significantly improved the prognostic value of the CRB/CURB-65 scores in CAP patients. Lactate may therefore be considered a rapid, cheap and broadly available additional criterion for the assessment of risk in patients with CAP.
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Affiliation(s)
- F S Frenzen
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - U Kutschan
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - N Meiswinkel
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - B Schulte-Hubbert
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - S Ewig
- Thoraxzentrum Ruhrgebiet, Department of Respiratory and Infectious Diseases, EVK Herne and Augusta-Kranken-Anstalt Bochum, Bochum, Germany
| | - M Kolditz
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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The long-term burden of severe sepsis and septic shock: Sepsis recidivism and organ dysfunction. J Trauma Acute Care Surg 2017; 81:525-32. [PMID: 27398984 DOI: 10.1097/ta.0000000000001135] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Severe sepsis and septic shock mortality has improved; however, rates of persistent (28-90 days) and long-term (>90 day) organ dysfunction in sepsis survivors are unknown. METHODS Secondary analysis of a prospective cohort of adult emergency department patients with severe sepsis. RESULTS Of 110 sepsis admissions, we obtained follow-up on 51 of 78 survivors of whom 41% (21 of 51) had persistent organ dysfunction: pulmonary, 18% (9 of 51); renal, 22% (11 of 51); coagulopathy, 10% (5 of 51); cardiovascular, 6% (3 of 51); hepatic, 2% (1 of 51); and neurologic, 3% (3 of 51). We obtained follow-up on 40 of 73 survivors at more than 90 days of whom 38% (15 of 40) had long-term organ dysfunction: pulmonary, 13% (5 of 40); renal, 18% (7 of 40); coagulopathy, 3% (1 of 40); cardiovascular, 5% (2 of 40); hepatic, 0%; and neurologic, 5% (2 of 40). Readmission rate within 90 days was 32% (25 of 78), and recurrent sepsis was the cause of readmission in 52% (13 of 25). Baseline SOFA scores from the index sepsis admission were compared using Wilcoxon rank-sum test and were significantly different in participants with organ dysfunction versus those without organ dysfunction at less than 90 days (z, -2.51; p = 0.01). CONCLUSION Readmission with recurrent sepsis and organ dysfunction occurs frequently in sepsis survivors. Baseline SOFA score may be predictive of sepsis recidivism and persistent or recurrent organ dysfunction. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level IV.
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The role of central venous oxygen saturation, blood lactate, and central venous-to-arterial carbon dioxide partial pressure difference as a goal and prognosis of sepsis treatment. J Crit Care 2016; 36:223-229. [DOI: 10.1016/j.jcrc.2016.08.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 07/13/2016] [Accepted: 08/06/2016] [Indexed: 01/01/2023]
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Vincent JL, Quintairos E Silva A, Couto L, Taccone FS. The value of blood lactate kinetics in critically ill patients: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:257. [PMID: 27520452 PMCID: PMC4983759 DOI: 10.1186/s13054-016-1403-5] [Citation(s) in RCA: 293] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 07/01/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND The time course of blood lactate levels could be helpful to assess a patient's response to therapy. Although the focus of published studies has been largely on septic patients, many other studies have reported serial blood lactate levels in different groups of acutely ill patients. METHODS We performed a systematic search of PubMed, Science Direct, and Embase until the end of February 2016 plus reference lists of relevant publications. We selected all observational and interventional studies that evaluated the capacity of serial blood lactate concentrations to predict outcome. There was no restriction based on language. We excluded studies in pediatric populations, experimental studies, and studies that did not report changes in lactate values or all-cause mortality rates. We separated studies according to the type of patients included. We collected data on the number of patients, timing of lactate measurements, minimum lactate level needed for inclusion if present, and suggested time interval for predictive use. RESULTS A total of 96 studies met our criteria: 14 in general ICU populations, five in general surgical ICU populations, five in patients post cardiac surgery, 14 in trauma patients, 39 in patients with sepsis, four in patients with cardiogenic shock, eight in patients after cardiac arrest, three in patients with respiratory failure, and four in other conditions. A decrease in lactate levels over time was consistently associated with lower mortality rates in all subgroups of patients. Most studies reported changes over 6, 12 or 24 hrs, fewer used shorter time intervals. Lactate kinetics did not appear very different in patients with sepsis and other types of patients. A few studies suggested that therapy could be guided by these measurements. CONCLUSIONS The observation of a better outcome associated with decreasing blood lactate concentrations was consistent throughout the clinical studies, and was not limited to septic patients. In all groups, the changes are relatively slow, so that lactate measurements every 1-2 hrs are probably sufficient in most acute conditions. The value of lactate kinetics appears to be valid regardless of the initial value.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Amanda Quintairos E Silva
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Lúcio Couto
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
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Ward MJ, Self WH, Singer A, Lazar D, Pines JM. Cost-effectiveness analysis of early point-of-care lactate testing in the emergency department. J Crit Care 2016; 36:69-75. [PMID: 27546750 DOI: 10.1016/j.jcrc.2016.06.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 06/03/2016] [Accepted: 06/30/2016] [Indexed: 12/29/2022]
Abstract
PURPOSE To determine the cost-effectiveness of implementing a point-of-care (POC) Lactate Program in the emergency department (ED) for patients with suspected sepsis to identify patients who can benefit from early resuscitation. MATERIALS AND METHODS We constructed a cost-effectiveness model to examine an ED with 30 000 patients annually. We evaluated a POC lactate program screening patients with suspected sepsis for an elevated lactate ≥4 mmol/L. Those with elevated lactate levels are resuscitated and their lactate clearance is evaluated by serial POC lactate measurements. The POC Lactate Program was compared with a Usual Care Strategy in which all patients with sepsis and an elevated lactate are admitted to the intensive care unit. Costs were estimated from the 2014 Medicare Inpatient and National Physician Fee schedules, and hospital and industry estimates. RESULTS In the base-case, the POC Lactate Program cost $39.53/patient whereas the Usual Care Strategy cost $33.20/patient. The screened patients in the POC arm resulted in 1.07 quality-adjusted life years for an incremental cost-effectiveness ratio of $31 590 per quality-adjusted life year gained, well below accepted willingness-to-pay-thresholds. CONCLUSIONS Implementing a POC Lactate Program for screening ED patients with suspected sepsis is a cost-effective intervention to identify patients responsive to early resuscitation.
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Affiliation(s)
- Michael J Ward
- Department of Emergency Medicine, Vanderbilt University School of Medicine, 1313 21(st) Ave South, Nashville, TN 37232.
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Adam Singer
- Department of Emergency Medicine, Stony Brook Medicine, Stony Brook, NY
| | - Danielle Lazar
- Office for Clinical Practice Innovation, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Jesse M Pines
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC; Department of Health Policy, George Washington University School of Medicine and Health Sciences, Washington, DC
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Freestanding Emergency Critical Care During the Aftermath of Hurricane Sandy: Implications for Disaster Preparedness and Response. Disaster Med Public Health Prep 2016; 10:496-502. [PMID: 27174171 DOI: 10.1017/dmp.2016.84] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To assess the impact of an emergency intensive care unit (EICU) established concomitantly with a freestanding emergency department (ED) during the aftermath of Hurricane Sandy. METHODS We retrospectively reviewed records of all patients in Bellevue's EICU from freestanding ED opening (December 10, 2012) until hospital inpatient reopening (February 7, 2013). Temporal and clinical data, and disposition upon EICU arrival, and ultimate disposition were evaluated. RESULTS Two hundred twenty-seven patients utilized the EICU, representing approximately 1.8% of freestanding ED patients. Ambulance arrival occurred in 31.6% of all EICU patients. Median length of stay was 11.55 hours; this was significantly longer for patients requiring airborne isolation (25.60 versus 11.37 hours, P<0.0001 by Wilcoxon rank sum test). After stabilization and treatment, 39% of EICU patients had an improvement in their disposition status (P<0.0001 by Wilcoxon signed rank test); upon interhospital transfer, the absolute proportion of patients requiring ICU and SDU resources decreased from 37.8% to 27.1% and from 22.2% to 2.7%, respectively. CONCLUSIONS An EICU attached to a freestanding ED achieved significant reductions in resource-intensive medical care. Flexible, adaptable care systems should be explored for implementation in disaster response. (Disaster Med Public Health Preparedness. 2016;10:496-502).
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Abstract
Physicians often prescribe vasopressors to correct pathological vasodilation and improve tissue perfusion in patients with septic shock, but the evidence to inform practice on vasopressor dosing is weak. We undertook a systematic review of clinical studies evaluating different blood pressure targets for the dosing of vasopressors in septic shock. We searched MEDLINE, EMBASE, CENTRAL (to November 2013), reference lists from included articles, and trial registries for randomized controlled trials (RCTs) and observational and crossover intervention studies comparing different blood pressure targets for vasopressor therapy in septic shock. Two reviewers independently selected eligible studies and extracted data on standardized forms. We identified 2 RCTs and 10 crossover trials but no observational studies meeting our criteria. Only one RCT measured clinical outcomes after comparing mean arterial pressure targets of 80 to 85 mmHg versus 65 to 70 mmHg. There was no effect on 28-day mortality, but confidence intervals were wide (hazard ratio, 95% confidence interval [95% CI] 0.84 - 1.38). In contrast, this intervention was associated with a greater risk of atrial fibrillation (relative risk, 2.36; 95% CI, 1.18 - 4.72) and a lower risk of renal replacement therapy in hypertensive patients (relative risk, 0.75; 95% CI, 0.57 - 1.0). Crossover trials suggest that achieving higher blood pressure targets by increasing vasopressor doses increases heart rate and cardiac index with no effect on serum lactate. Our findings underscore the paucity of clinical evidence to guide the administration of vasopressors in critically ill patients with septic shock. Further rigorous research is needed to establish an evidence base for vasopressor administration in this population.
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Suetrong B, Walley KR. Lactic Acidosis in Sepsis: It's Not All Anaerobic: Implications for Diagnosis and Management. Chest 2016; 149:252-61. [PMID: 26378980 DOI: 10.1378/chest.15-1703] [Citation(s) in RCA: 212] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 08/24/2015] [Accepted: 08/31/2015] [Indexed: 12/21/2022] Open
Abstract
Increased blood lactate concentration (hyperlactatemia) and lactic acidosis (hyperlactatemia and serum pH < 7.35) are common in patients with severe sepsis or septic shock and are associated with significant morbidity and mortality. In some patients, most of the lactate that is produced in shock states is due to inadequate oxygen delivery resulting in tissue hypoxia and causing anaerobic glycolysis. However, lactate formation during sepsis is not entirely related to tissue hypoxia or reversible by increasing oxygen delivery. In this review, we initially outline the metabolism of lactate and etiology of lactic acidosis; we then address the pathophysiology of lactic acidosis in sepsis. We discuss the clinical implications of serum lactate measurement in diagnosis, monitoring, and prognostication in acute and intensive care settings. Finally, we explore treatment of lactic acidosis and its impact on clinical outcome.
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Affiliation(s)
- Bandarn Suetrong
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada
| | - Keith R Walley
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada.
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Purcarea A, Bourgarit A, Sovaila A, Ghiura C, Diemunsch P, Andres E. Brief report: Serial capillary lactate measurement predict the evolution of early sepsis. J Med Life 2016; 9:74-78. [PMID: 27974919 PMCID: PMC5152613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE In intensive care settings, blood lactate level measurement proved to be an excellent predictor of outcomes. In patients requiring less urgent treatment, the arterial blood lactate is less sensitive and its usefulness remains to be proven. Capillary blood lactate dosing, an emergent point-of-care technique readily available should be more sensitive to changes in these settings. METHOD prospective, observational, monocentric study conducted in a polyvalent internal medicine ward in a French University Hospital. The inclusion criteria were the existence of new symptoms of abrupt onset in an otherwise stable patient. All the patients had a point of care measurement of baseline capillary and venous lactate levels (EDGE, ApexBio) and standardized control before any therapeutic means were initiated. A follow-up test was performed once again within 12 to 36 hours. All the patients received standard medical care adapted to their condition. The primary outcomes were considered dying within 30 days or requiring intensive care or invasive therapeutic procedures. RESULTS 13 patients were analyzed. Seven patients reached the composite outcome with 3 deaths. The superimposed complication proved to be infectious in every case. The median lactate levels were at baseline (mmol/ l): capillary Mc0=5.2(2.16), venous Mv0=2.3(2.0) and arterial Ma0=1.8(1.7) and at follow-up (mmol/ l) capillary: Mc1=3.3(1.1), venous Mv1=1.8(1.8) and arterial Ma1=1.3(0.7). In nonparametric analysis, the absence of normalization of capillary lactate at follow-up was correlated well with poor outcomes (p=.05). This was not the case of arterial or venous lactate measurements. The positive lactate clearance was present in the majority of patients (83.3%) but it did not predict the outcomes (p=.435) and there was no correlation between the baseline lactate and the clinical outcome (p>.05). CONCLUSION In non intensive care settings, capillary lactate level could be a more sensitive method than the classical lactate measurement for predicting the outcomes of acute conditions, especially infectious. A persistently high lactate level rather than its initial value or clearance seems to correlate better with poorer outcomes. ABBREVIATIONS SSC = Surviving sepsis campaign, ED = Emergency department, ICU = intensive care unit, , POC = Point of care, ICC = inter class coefficient.
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Affiliation(s)
- A Purcarea
- Internal Medicine, “Hopital Civil” Hospital, Strasbourg, France,Internal Medicine Department, Internist.ro, Brasov, Romania
| | - A Bourgarit
- Internal Medicine Department, Internist.ro, Brasov, Romania,Internal Medicine, “Hautepierre” Hospital, Strasbourg, France
| | - A Sovaila
- Internal Medicine Department, Internist.ro, Brasov, Romania,Internal Medicine, “Hautepierre” Hospital, Strasbourg, France
| | - C Ghiura
- Internal Medicine, “Hopital Civil” Hospital, Strasbourg, France
| | - P Diemunsch
- Anesthesiology, Critical Care and Prehospital Emergency Medicine, Strasbourg, France
| | - E Andres
- Internal Medicine, “Hopital Civil” Hospital, Strasbourg, France
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Dettmer MR, Mohr NM, Fuller BM. Sepsis-associated pulmonary complications in emergency department patients monitored with serial lactate: An observational cohort study. J Crit Care 2015; 30:1163-8. [PMID: 26362864 PMCID: PMC4648355 DOI: 10.1016/j.jcrc.2015.07.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 07/27/2015] [Accepted: 07/29/2015] [Indexed: 12/29/2022]
Abstract
PURPOSE Patients with severe sepsis and septic shock are at high risk for development of pulmonary complications, including acute respiratory distress syndrome (ARDS). Serial lactate monitoring is a useful tool to gauge global tissue hypoxia in emergency department (ED) patients with sepsis. We hypothesized that patients undergoing serial lactate monitoring (SL) would demonstrate a decreased incidence of pulmonary complications. METHODS This is a retrospective observational cohort study of adult severe sepsis and septic shock patients with elevated lactate presenting to a large academic ED. A total of 243 patients were assigned to SL (n=132) or no serial lactate monitoring (NL; n=111). The primary outcome was a composite of pulmonary complications: (1) ARDS development and (2) respiratory failure. RESULTS Twenty-eight patients (21%) in the SL group and 37 patients (33%) in the NL group developed the primary outcome (P=.03). Multivariate analysis demonstrated an association between the NL group and development of pulmonary complications (adjusted odds ratio [aOR], 2.1; confidence interval [CI], 1.15-3.78). Emergency department mechanical ventilation was independently associated with development of ARDS (aOR, 3.5; 1.8-7.0). In the a priori subgroup of patients mechanically ventilated in the ED (n=97), those who developed ARDS received higher tidal volumes compared to patients who did not develop ARDS (8.7 mL/kg predicted body weight [interquartile range, 7.6-9.5] vs 7.6 [interquartile range, 6.8-9.0]; P<.01). CONCLUSIONS Serial lactate monitoring is associated with a decrease in major pulmonary complications in severe sepsis and septic shock. Acute respiratory distress syndrome incidence is also influenced by ED-based mechanical ventilation. These results provide 2 potentially modifiable variables to be targeted in future studies to prevent pulmonary complications in this patient subset.
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Affiliation(s)
- Matthew R Dettmer
- Division of Critical Care Medicine, Department of Medicine, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ 08103.
| | - Nicholas M Mohr
- Department of Emergency Medicine, Roy J. Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA 52242; Division of Critical Care, Department of Anesthesia, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA 52242.
| | - Brian M Fuller
- Division of Emergency Medicine, Washington University School of Medicine in St Louis, St Louis, MO 63110; Division of Critical Care, Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, MO 63110.
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The prognostic role of non-critical lactate levels for in-hospital survival time among ED patients with sepsis. Am J Emerg Med 2015; 34:170-3. [PMID: 26549000 DOI: 10.1016/j.ajem.2015.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 09/28/2015] [Accepted: 10/02/2015] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE This study describes emergency department (ED) sepsis patients with non-critical serum venous lactate (LAC) levels (LAC <4.0 mmol/L) who suffered in-hospital mortality and examines LAC in relation to survival times. METHODS An ED based retrospective cohort study accrued September 2010 to August 2014. Inclusion criteria were ED admission, LAC sampling, >2 systemic inflammatory response syndrome criteria with an infectious source (sepsis), and in-hospital mortality. Kaplan-Meier curves were used for survival estimates. An a priori sub-group analysis for patients with repeat LAC within 6 hours of initial sampling was undertaken. The primary outcome was time to in-hospital death evaluated using rank-sum tests and regression models. RESULTS One hundred ninety-seven patients met inclusion criteria. Pulmonary infections were the most common (44%) and median LAC was 1.9 mmol/L (1.5, 2.5). Thirteen patients (7%) died within 24 hours and 79% by ≤28 days. Median survival was 11 days (95% CI, 8.0-13). Sixty-two patients had repeat LAC sampling with 14 (23%) and 48 (77%) having decreasing increasing levels, respectively. No significant differences were observed in treatment requirements between the LAC subgroups. Among patients with decreasing LAC, median survival was 24 days (95% CI, 5-32). For patients with increasing LAC median survival was significantly shorter (7 days; 95% CI, 4-11, P = .04). Patients with increasing LAC had a non-significant trend toward reduced survival (HR = 1.6 95% CI, 0.90-3.0, P = .10). CONCLUSIONS In septic ED patients experiencing in-hospital death, non-critical serum venous lactate may be utilized as a risk-stratifying tool for early mortality, while increasing LAC levels may identify those in danger of more rapid deterioration.
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Wong KK, Perdue CL, Malia J, Kenney JL, Peng S, Gwathney JK, Raczniak GA. Supportive Care of the First 2 Ebola Virus Disease Patients at the Monrovia Medical Unit. Clin Infect Dis 2015; 61:e47-51. [PMID: 26021993 DOI: 10.1093/cid/civ420] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 05/15/2015] [Indexed: 11/15/2022] Open
Abstract
We describe the first 2 patients admitted to the Monrovia Medical Unit, a facility established to treat Liberian and international response workers with suspected or known Ebola virus disease (EVD). Their recoveries illustrate the value of local point-of-care diagnostics, parenteral therapies, and electrolyte replacement in EVD supportive care.
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Affiliation(s)
- Karen K Wong
- United States Public Health Service, Rockville, Maryland
| | | | - Jennifer Malia
- United States Public Health Service, Rockville, Maryland
| | - James L Kenney
- United States Public Health Service, Rockville, Maryland
| | - Suzette Peng
- United States Public Health Service, Rockville, Maryland
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What’s New in Shock, JANUARY 2015? Shock 2015; 43:1-2. [DOI: 10.1097/shk.0000000000000287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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