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Orso D, Federici N, Lio C, Mearelli F, Bove T. Hemodynamic goals in sepsis and septic shock resuscitation: An umbrella review of systematic reviews and meta-analyses with trial sequential analysis. Aust Crit Care 2024; 37:818-826. [PMID: 38609748 DOI: 10.1016/j.aucc.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 03/03/2024] [Accepted: 03/18/2024] [Indexed: 04/14/2024] Open
Abstract
OBJECTIVE The objective of this study was to verify whether any parameter among those used as the target for haemodynamic optimisation (e.g., mean arterial pressure, central venous oxygen saturation, systolic or diastolic dysfunction, CO2 gap, lactates, right ventricular dysfunction, and PvaCO2/CavO2 ratio) is correlated with mortality in an undifferentiated population with sepsis or septic shock. METHODS An umbrella review, searching MEDLINE, the Cochrane Database of Systematic Reviews, Health Technology Assessment Database, and the JBI Database of Systematic Reviews and Implementation Reports, was performed. We included systematic reviews and meta-analyses enrolling a population of unselected patients with sepsis or septic shock. The main outcome was mortality. Two authors conducted data extraction and risk-of-bias assessments independently. We used a random-effects model to pool binary and continuous data and summarised estimates of effect using equivalent odds ratios (eORs). We used the ROBIS tool to assess risk of bias and the assessment of multiple systematic reviews 2 score to assess global quality. DATA SYNTHESIS 17 systematic reviews and meta-analyses (15 828 patients) were included in the quantitative analysis. Diastolic dysfunction (eOR: 1.42; 95% confidence interval [CI]: 1.14-1.76), PvaCO2/CavO2 ratio (eOR: 2.15; 95% CI: 1.37-3.37), and CO2 gap (eOR: 1.86; 95% CI: 1.07-3.25) showed a significant correlation with mortality. Lactates were the parameter with highest inconsistency (I2 = 92%). Central venous oxygen saturation and right ventricle dysfunction showed significant statistical excess test of significance (p-value = 0.009 and 0.005, respectively). None of the considered parameters showed statistically significant publication bias. CONCLUSIONS According to this umbrella review, diastolic dysfunction is the haemodynamic variable that is most closely linked to the prognosis of septic patients. The PvaCO2/CavO2 ratio and the CO2gap are significantly related to the mortality of septic patients, but the poor quality of evidence or the low number of cases, studied so far, limit their clinical applicability. CLINICAL TRIAL REGISTRATION PROSPERO: International prospective register of systematic reviews, 2023, CRD42023432813 (Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023432813).
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Affiliation(s)
- Daniele Orso
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy.
| | - Nicola Federici
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | - Cristina Lio
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy; Department of Medical Sciences (DAME), University of Udine, Udine, Italy
| | - Filippo Mearelli
- Department of Internal Medicine, ASUGI University Hospital of Trieste, Trieste, Italy
| | - Tiziana Bove
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy; Department of Medical Sciences (DAME), University of Udine, Udine, Italy
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2
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Billig H, Al Zaidi M, Quacken F, Görtzen-Patin J, Goody PR, Gräff I, Nickenig G, Zimmer S, Aksoy A. Blood glucose and lactate levels as early predictive markers in patients presenting with cardiogenic shock: A retrospective cohort study. PLoS One 2024; 19:e0306107. [PMID: 39052641 PMCID: PMC11271948 DOI: 10.1371/journal.pone.0306107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 06/11/2024] [Indexed: 07/27/2024] Open
Abstract
Lactate and glucose are widely used biochemical parameters in current predictive risk scores for cardiogenic shock. Data regarding the relationship between lactate and glucose levels in cardiogenic shock are limited. Thus, we aimed to analyze glucose and lactate as early markers for in-hospital mortality in cardiogenic shock. In this retrospective cohort study, 312 patients presenting with cardiogenic shock to a tertiary-care hospital between 2016 and 2018 were included. Apparent cardiogenic shock was defined as hypoperfusion with hemodynamic compromise and biochemical marker increase due to diminished tissue perfusion, corresponding to SCAI shock stages. In-hospital mortality was assessed as the primary endpoint. The median age of the study population was 71 (60-79) years and the etiology of cardiogenic shock was acute myocardial infarction in 45.8%. Overall in-hospital mortality was 67.6%. In the receiver operating curve analysis, the area under the receiver-operating curve (AUC) for prediction of in-hospital mortality was higher for lactate (AUC: 0.757) than for glucose (AUC: 0.652). Both values were significantly associated with outcome (groups created with best cutoff values obtained from the Youden index). Correlation analysis showed a significant non-linear association of both values. In a multivariable stepwise Cox regression analysis, lactate remained an independent predictor for in-hospital mortality, whilst glucose, despite being implicated in energy metabolism, was not independently predictive for mortality. Together, these data suggest that lactate at admission is superior for mortality prediction in patients with apparent cardiogenic shock. Glucose was not independently predictive for mortality.
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Affiliation(s)
- Hannah Billig
- Department of Cardiology—University Hospital Bonn, Bonn, Germany
| | | | - Florian Quacken
- Department of Cardiology—University Hospital Bonn, Bonn, Germany
| | | | | | - Ingo Gräff
- Department of clinical acute- and emergency medicine, University Hospital Bonn, Bonn, Germany
| | - Georg Nickenig
- Department of Cardiology—University Hospital Bonn, Bonn, Germany
| | - Sebastian Zimmer
- Department of Cardiology—University Hospital Bonn, Bonn, Germany
| | - Adem Aksoy
- Department of Cardiology—University Hospital Bonn, Bonn, Germany
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3
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Tonai K, Katayama S, Koyama K, Imahase H, Nunomiya S. Association between hypomagnesemia and serum lactate levels in patients with sepsis: a retrospective observational study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:23. [PMID: 38570893 PMCID: PMC10988873 DOI: 10.1186/s44158-024-00158-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 03/25/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Sepsis-3 emphasizes the recognition of sepsis-induced cellular metabolic abnormalities, and utilizes serum lactate level as a biomarker of cellular metabolic abnormalities. Magnesium plays an important role as a cofactor in glucose metabolism, although it is not well known that magnesium deficiency causes elevated serum lactate levels. Additionally, it remains unclear how magnesium status affects the role of serum lactate levels as a marker of metabolic abnormalities in sepsis. Thus, this study aimed to investigate the association between serum magnesium and lactate levels in patients with sepsis and explore this relationship from the perspectives of time course and circulatory abnormalities. METHODS This retrospective observational study of adult patients with sepsis was performed at the 16-bed intensive care unit of Jichi Medical University Hospital between June 2011 and December 2017. The relationship between serum magnesium and lactate levels for 5 days from intensive care unit admission was investigated along the time course. Multivariate logistic regression analysis was performed to evaluate the association between serum magnesium and lactate levels during intensive care unit admission. RESULTS Among 759 patients included, 105 had hypomagnesemia (magnesium level < 1.6 mg/dL), 558 had normal serum magnesium levels (1.6-2.4 mg/dL), and 96 had hypermagnesemia (magnesium level > 2.4 mg/dL) at intensive care unit admission. From intensive care unit admission to day 5, the hypomagnesemia group had higher serum lactate levels and a higher frequency of lactic acidosis than the normal magnesium level and hypermagnesemia groups (70% vs. 51.6% vs. 50%; P < 0.001). Hypomagnesemia at intensive care unit admission was independently associated with lactic acidosis, i.e., lactic acid level > 2 mmol/L (odds ratio, 2.76; 95% confidence interval, 1.60-4.76; P < 0.001). CONCLUSIONS Hypomagnesemia was associated with serum lactate levels in the early and post-resuscitation phases of sepsis. Further studies are needed to elucidate whether the magnesium status is associated with sepsis-induced cellular and metabolic abnormalities.
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Affiliation(s)
- Ken Tonai
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Tochigi, Japan.
| | - Shinshu Katayama
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Kansuke Koyama
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Hisashi Imahase
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Shin Nunomiya
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
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4
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Zhang S, Liu W, Ganz T, Liu S. Exploring the relationship between hyperlactatemia and anemia. Trends Endocrinol Metab 2024; 35:300-307. [PMID: 38185594 DOI: 10.1016/j.tem.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 01/09/2024]
Abstract
Hyperlactatemia and anemia commonly coexist and their crosstalk is a longstanding mystery with elusive mechanisms involved in physical activities, infections, cancers, and genetic disorders. For instance, hyperlactatemia leads to iron restriction by upregulating hepatic hepcidin expression. Increasing evidence also points to lactate as a crucial signaling molecule rather than merely a metabolic byproduct. Here, we discuss the mutual influence between anemia and hyperlactatemia. This opinion calls for a reconsideration of the multifaceted roles of lactate and lactylation in anemia and emphasizes the need to fill knowledge gaps, including the dose dependence of lactate's effects, its sources, and its subcellular localization.
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Affiliation(s)
- Shuping Zhang
- Medical Science and Technology Innovation Center, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong 250117, China
| | - Wei Liu
- Medical Science and Technology Innovation Center, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong 250117, China; State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
| | - Tomas Ganz
- Center for Iron Disorders, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
| | - Sijin Liu
- Medical Science and Technology Innovation Center, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong 250117, China; State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China; University of Chinese Academy of Sciences, Beijing 100049, China.
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5
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Yoon BR, Seol CH, Min IK, Park MS, Park JE, Chung KS. Biomarker-Based Assessment Model for Detecting Sepsis: A Retrospective Cohort Study. J Pers Med 2023; 13:1195. [PMID: 37623446 PMCID: PMC10455581 DOI: 10.3390/jpm13081195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/26/2023] Open
Abstract
The concept of the quick sequential organ failure assessment (qSOFA) simplifies sepsis detection, and the next SOFA should be analyzed subsequently to diagnose sepsis. However, it does not include the concept of suspected infection. Thus, we simply developed a biomarker-based assessment model for detecting sepsis (BADS). We retrospectively reviewed the electronic health records of patients admitted to the intensive care unit (ICU) of a 2000-bed university tertiary referral hospital in South Korea. A total of 989 patients were enrolled, with 77.4% (n = 765) of them having sepsis. The patients were divided into a ratio of 8:2 and assigned to a training and a validation set. We used logistic regression analysis and the Hosmer-Lemeshow test to derive the BADS and assess the model. BADS was developed by analyzing the variables and then assigning weights to the selected variables: mean arterial pressure, shock index, lactate, and procalcitonin. The area under the curve was 0.754, 0.615, 0.763, and 0.668 for BADS, qSOFA, SOFA, and acute physiology and chronic health evaluation (APACHE) II, respectively, showing that BADS is not inferior in sepsis prediction compared with SOFA. BADS could be a simple scoring method to detect sepsis in critically ill patients quickly at the bedside.
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Affiliation(s)
- Bo Ra Yoon
- Department of Internal Medicine, New Korea Hospital, Gimpo-si 10086, Republic of Korea;
| | - Chang Hwan Seol
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin 16995, Republic of Korea;
| | - In Kyung Min
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Min Su Park
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Ji Eun Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea
| | - Kyung Soo Chung
- Division of Pulmonology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
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6
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Brinkmann C, Bloch W, Mutinati GC. ELSAH (electronic smart patch system for wireless monitoring of molecular biomarkers for healthcare and wellbeing): definition of possible use cases. Front Bioeng Biotechnol 2023; 11:1166857. [PMID: 37251564 PMCID: PMC10211345 DOI: 10.3389/fbioe.2023.1166857] [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: 02/15/2023] [Accepted: 04/18/2023] [Indexed: 05/31/2023] Open
Abstract
The ELSAH (electronic smart patch system for wireless monitoring of molecular biomarkers for healthcare and wellbeing) project has received funding from EU's Horizon 2020 research and innovation program (grant agreement no. 825549). Its aim is to develop a wearable smart patch-based microneedle sensor system that can simultaneously measure several biomarkers in users' dermal interstitial fluid. This system could have several use cases based on continuous glucose and lactate monitoring: early detection of (pre-) diabetes mellitus, increasing physical performance through optimal carbohydrate intake, achieving a healthier lifestyle through behavioral changes based on the interpretation of glucose data, performance diagnostics (lactate threshold test), control of optimal training intensities corresponding with certain lactate levels, or warning of diseases/health threats, such as the metabolic syndrome or sepsis associated with increased lactate levels. The ELSAH patch system has a high potential of increasing health and wellbeing in users.
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Affiliation(s)
- Christian Brinkmann
- Department of Preventive and Rehabilitative Sport Medicine, Institute of Cardiovascular Research and Sport Medicine, German Sport University Cologne, Cologne, Germany
- Department of Fitness and Health, IST University of Applied Sciences, Düsseldorf, Germany
| | - Wilhelm Bloch
- Department of Preventive and Rehabilitative Sport Medicine, Institute of Cardiovascular Research and Sport Medicine, German Sport University Cologne, Cologne, Germany
| | - Giorgio C. Mutinati
- AIT Austrian Institute of Technology GmbH, Center for Health and Bioresources, Molecular Diagnostics, Vienna, Austria
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7
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Allo G, Gillessen J, Gülcicegi D, Kasper P, Chon SH, Goeser T, Bürger M. Comparison of Lactate Clearance with Established Risk Assessment Tools in Predicting Outcomes in Acute Upper Gastrointestinal Bleeding. J Clin Med 2023; 12:jcm12072716. [PMID: 37048800 PMCID: PMC10095270 DOI: 10.3390/jcm12072716] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 04/14/2023] Open
Abstract
Early risk stratification is mandatory in acute upper gastrointestinal bleeding (AUGIB) to guide optimal treatment. Numerous risk scores were introduced, but lack of practicability led to limited use in daily clinical practice. Lactate clearance is an established risk assessment tool in a variety of diseases, such as trauma and sepsis. Therefore, this study compares the predictive ability of pre-endoscopic lactate clearance and established risk scores in patients with AUGIB at the University Hospital of Cologne. Active bleeding was detected in 27 (25.2%) patients, and hemostatic intervention was performed in 35 (32.7%). In total, 16 patients (15%) experienced rebleeding and 12 (11.2%) died. Initially, lactate levels were elevated in 64 cases (59.8%), and the median lactate clearance was 18.7% (2.7-48.2%). Regarding the need for endoscopic intervention, the predictive ability of Glasgow Blatchford Score, pre-endoscopic Rockall score, initial lactate and lactate clearance did not differ significantly, and their area under the receiver operating characteristic curves were 0.658 (0.560-0.747), 0.572 (0.473-0.667), 0.572 (0.473-0.667) and 0.583 (0.483-0.677), respectively. Similar results were observed in relation to rebleeding and mortality. In conclusion, lactate clearance had comparable predictive ability compared to established risk scores. Further prospective research is necessary to clarify the potential role of lactate clearance as a reliable risk assessment tool in AUGIB.
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Affiliation(s)
- Gabriel Allo
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Johannes Gillessen
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Dilan Gülcicegi
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Philipp Kasper
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Seung-Hun Chon
- Department of General, Visceral and Cancer and Transplant Surgery, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany
| | - Tobias Goeser
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Martin Bürger
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
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Balmuchu G, Mohanty MK, Sahu MR, Hansda U, Naveen A, Lenka PK. Outcome prediction using sequential organ failure assessment (SOFA) score and serum lactate levels in organophosphate poisoning. J Family Med Prim Care 2023; 12:777-782. [PMID: 37312768 PMCID: PMC10259572 DOI: 10.4103/jfmpc.jfmpc_1713_22] [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: 08/27/2022] [Revised: 01/25/2023] [Accepted: 02/02/2023] [Indexed: 06/15/2023] Open
Abstract
Background Organophosphorus compounds are widely used as pesticides in agriculture practicing countries like India. Since it is readily available and accessible, it is one of the most commonly used agents for suicidal poisoning. The current study was undertaken to evaluate the performance of the SOFA score (scoring system) and the serum lactate level (laboratory parameter) as a mortality predictor in organophosphorus poisoning. Material and Methods This prospective observational study was conducted at AIIMS, Bhubaneswar, for 17 months. The study population included all patients with an alleged history of ingestion of organophosphorus (OP) compounds reporting to the casualty. The receiver operating characteristic (ROC) curve and the logistic regression analysis were used for the analysis. Results In our study, 75 patients with OP poisoning were studied after satisfying the inclusion criteria. OP poisoning was commonly seen in married males aged 21-40 years. Twelve (16%) patients died during the process of treatment. There was a statistically significant difference in the mean SOFA score, serum lactate level, pH value, and mean duration of hospital stay between the discharged and the deceased patients. In the current study, the ROC curve analysis used to assess the predictor of the outcome of OP poisoning showed that the area under the curve for SOFA score and serum lactate level were 0.794 (95% CI 0.641-0.948) and 0.659 (95% CI 0.472-0.847), respectively. Conclusion Sequential Organ Failure Assessment (SOFA) score is significantly associated with the outcome of organophosphate poisoning and can be utilized to predict mortality.
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Affiliation(s)
- Govinda Balmuchu
- Department of Forensic Medicine and Toxicology, AIIMS, Bhubaneswar, Odisha, India
| | - Manoj K. Mohanty
- Department of Forensic Medicine and Toxicology, AIIMS, Bhubaneswar, Odisha, India
| | - Manas R. Sahu
- Department of Forensic Medicine and Toxicology, AIIMS, Bhubaneswar, Odisha, India
| | - Upendra Hansda
- Department of Trauma and Emergency, AIIMS, Bhubaneswar, Odisha, India
| | - Alagarasan Naveen
- Department of Forensic Medicine and Toxicology, SRM Medical College & Research Centre, Chengalpattu, Tamil Nadu, India
| | - Preetam K. Lenka
- Department of Forensic Medicine and Toxicology, IMS & SUM Hospital, Bhubaneswar, Odisha, India
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9
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Kim SG, Lee J, Yun D, Kang MW, Kim YC, Kim DK, Oh KH, Joo KW, Kim YS, Han SS. Hyperlactatemia is a predictor of mortality in patients undergoing continuous renal replacement therapy for acute kidney injury. BMC Nephrol 2023; 24:11. [PMID: 36641421 PMCID: PMC9840420 DOI: 10.1186/s12882-023-03063-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/12/2023] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Hyperlactatemia occurs frequently in critically ill patients, and this pathologic condition leads to worse outcomes in several disease subsets. Herein, we addressed whether hyperlactatemia is associated with the risk of mortality in patients undergoing continuous renal replacement therapy (CRRT) due to acute kidney injury. METHODS A total of 1,661 patients who underwent CRRT for severe acute kidney injury were retrospectively reviewed between 2010 and 2020. The patients were categorized according to their serum lactate levels, such as high (≥ 7.6 mmol/l), moderate (2.1-7.5 mmol/l) and low (≤ 2 mmol/l), at the time of CRRT initiation. The hazard ratios (HRs) for the risk of in-hospital mortality were calculated with adjustment of multiple variables. The increase in the area under the receiver operating characteristic curve (AUROC) for the mortality risk was evaluated after adding serum lactate levels to the Sequential Organ Failure Assessment (SOFA) and the Acute Physiology and Chronic Health Evaluation (APACHE) II score-based models. RESULTS A total of 802 (48.3%) and 542 (32.6%) patients had moderate and high lactate levels, respectively. The moderate and high lactate groups had a higher risk of mortality than the low lactate group, with HRs of 1.64 (1.22-2.20) and 4.18 (2.99-5.85), respectively. The lactate-enhanced models had higher AUROCs than the models without lactates (0.764 vs. 0.702 for SOFA score; 0.737 vs. 0.678 for APACHE II score). CONCLUSIONS Hyperlactatemia is associated with mortality outcomes in patients undergoing CRRT for acute kidney injury. Serum lactate levels may need to be monitored in this patient subset.
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Affiliation(s)
- Seong Geun Kim
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080 Seoul, Korea
| | - Jinwoo Lee
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080 Seoul, Korea
| | - Donghwan Yun
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080 Seoul, Korea
| | - Min Woo Kang
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080 Seoul, Korea
| | - Yong Chul Kim
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080 Seoul, Korea
| | - Dong Ki Kim
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080 Seoul, Korea
| | - Kook-Hwan Oh
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080 Seoul, Korea
| | - Kwon Wook Joo
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080 Seoul, Korea
| | - Yon Su Kim
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080 Seoul, Korea
| | - Seung Seok Han
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080 Seoul, Korea
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Vintrych P, Al-Obeidallah M, Horák J, Chvojka J, Valešová L, Nalos L, Jarkovská D, Matějovič M, Štengl M. Modeling sepsis, with a special focus on large animal models of porcine peritonitis and bacteremia. Front Physiol 2023; 13:1094199. [PMID: 36703923 PMCID: PMC9871395 DOI: 10.3389/fphys.2022.1094199] [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: 11/09/2022] [Accepted: 12/28/2022] [Indexed: 01/12/2023] Open
Abstract
Infectious diseases, which often result in deadly sepsis or septic shock, represent a major global health problem. For understanding the pathophysiology of sepsis and developing new treatment strategies, reliable and clinically relevant animal models of the disease are necessary. In this review, two large animal (porcine) models of sepsis induced by either peritonitis or bacteremia are introduced and their strong and weak points are discussed in the context of clinical relevance and other animal models of sepsis, with a special focus on cardiovascular and immune systems, experimental design, and monitoring. Especially for testing new therapeutic strategies, the large animal (porcine) models represent a more clinically relevant alternative to small animal models, and the findings obtained in small animal (transgenic) models should be verified in these clinically relevant large animal models before translation to the clinical level.
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Affiliation(s)
- Pavel Vintrych
- Department of Cardiology, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Mahmoud Al-Obeidallah
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Jan Horák
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Jiří Chvojka
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Lenka Valešová
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Lukáš Nalos
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Dagmar Jarkovská
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Martin Matějovič
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Milan Štengl
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,*Correspondence: Milan Štengl,
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Klein-Richers U, Heitland A, Hartmann K, Dörfelt R. Influence of acetate- vs. lactate-containing fluid bolus therapy on acid-base status, electrolytes, and plasma lactate in dogs. Front Vet Sci 2022; 9:903091. [PMID: 35968021 PMCID: PMC9372486 DOI: 10.3389/fvets.2022.903091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/11/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveAcetate- and lactate-containing fluids influence the acid-base and electrolyte status. This prospective, randomized, clinical study compared two balanced crystalloid solutions regarding their influence on acid-base status, electrolytes, and lactate values, when given to dogs as a resuscitation bolus of 30 mL/kg.Material and methodsOne hundred client-owned dogs presenting to the emergency service with signs of fluid deficits were randomly assigned to receive an intravenous bolus of 30 mL/kg of either a lactate- (LAC), or an acetate-containing solution (ACET). Before and after the bolus, vital parameters were assessed, and a venous blood gas analysis was performed.ResultsBoth solutions performed equally well in decreasing the heart rate (ACET: −10 ± 27 bpm, LAC: −12 ± 30 bpm; p = 0.737). The acetate-containing solution caused a significant decrease in plasma lactate levels (p = 0.016), anion gap (p < 0.001), and potassium (p < 0.001), and a significant increase in chloride (p < 0.001), and ionized calcium (p = 0.014). The lactate-containing solution caused a significant decrease in anion gap (p < 0.001), sodium (p = 0.016), and potassium (p = 0.001), and a significant increase in chloride (p < 0.001). ACET causes a stronger decrease in plasma lactate (p = 0.015), sodium (p = 0.039), potassium (p = 0.006), and an increase in chloride (p < 0.001), and ionized calcium (p = 0.016) compared to LAC.ConclusionBoth solutions caused mild changes in electrolyte concentrations and had minor influence on acid-base status when used for bolus therapy in dogs with fluid deficits. Further studies are needed to evaluate their influence on acid-base status, lactate, and electrolytes when used in larger volumes and for a longer time span.
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Affiliation(s)
- Ute Klein-Richers
- Clinic of Small Animal Medicine, Center for Clinical Veterinary Medicine, LMU Munich, Munich, Germany
- *Correspondence: Ute Klein-Richers
| | | | - Katrin Hartmann
- Clinic of Small Animal Medicine, Center for Clinical Veterinary Medicine, LMU Munich, Munich, Germany
| | - René Dörfelt
- Clinic of Small Animal Medicine, Center for Clinical Veterinary Medicine, LMU Munich, Munich, Germany
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12
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Serum Lactate and Mortality during Pediatric Admissions: Is 2 Really the Magic Number? J Pediatr Intensive Care 2022; 11:83-90. [PMID: 35734205 PMCID: PMC9208839 DOI: 10.1055/s-0042-1743180] [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: 09/09/2021] [Accepted: 01/06/2021] [Indexed: 10/19/2022] Open
Abstract
The primary objective of this study was to determine if serum lactate level at the time of hospital admission can predict mortality in pediatric patients. A systematic review was conducted to identify studies that assessed the utility of serum lactate at the time of admission to predict mortality in pediatric patients. The areas under the curve from the receiver operator curve analyses were utilized to determine the pooled area under the curve. Additionally, standardized mean difference was compared between those who survived to discharge and those who did not. A total of 12 studies with 2,099 patients were included. Out of these, 357 (17%) experienced mortality. The pooled area under the curve for all patients was 0.74 (0.67-0.80, p < 0.01). The pooled analyses for all admissions were higher in those who experienced mortality (6.5 vs. 3.3 mmol/L) with a standardized mean difference of 2.60 (1.74-3.51, p < 0.01). The pooled area under the curve for cardiac surgery patients was 0.63 (0.53-0.72, p < 0.01). The levels for cardiac surgery patients were higher in those who experienced mortality (5.5 vs. 4.1 mmol/L) with a standardized mean difference of 1.80 (0.05-3.56, p = 0.04). Serum lactate at the time of admission can be valuable in identifying pediatric patients at greater risk for inpatient mortality. This remained the case when only cardiac surgery patients were included.
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13
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Machine Learning Prediction Models for Mortality in Intensive Care Unit Patients with Lactic Acidosis. J Clin Med 2021; 10:jcm10215021. [PMID: 34768540 PMCID: PMC8584535 DOI: 10.3390/jcm10215021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Lactic acidosis is the most common cause of anion gap metabolic acidosis in the intensive care unit (ICU), associated with poor outcomes including mortality. We sought to compare machine learning (ML) approaches versus logistic regression analysis for prediction of mortality in lactic acidosis patients admitted to the ICU. Methods: We used the Medical Information Mart for Intensive Care (MIMIC-III) database to identify ICU adult patients with lactic acidosis (serum lactate ≥4 mmol/L). The outcome of interest was hospital mortality. We developed prediction models using four ML approaches consisting of random forest (RF), decision tree (DT), extreme gradient boosting (XGBoost), artificial neural network (ANN), and statistical modeling with forward stepwise logistic regression using the testing dataset. We then assessed model performance using area under the receiver operating characteristic curve (AUROC), accuracy, precision, error rate, Matthews correlation coefficient (MCC), F1 score, and assessed model calibration using the Brier score, in the independent testing dataset. Results: Of 1919 lactic acidosis ICU patients, 1535 and 384 were included in the training and testing dataset, respectively. Hospital mortality was 30%. RF had the highest AUROC at 0.83, followed by logistic regression 0.81, XGBoost 0.81, ANN 0.79, and DT 0.71. In addition, RF also had the highest accuracy (0.79), MCC (0.45), F1 score (0.56), and lowest error rate (21.4%). The RF model was the most well-calibrated. The Brier score for RF, DT, XGBoost, ANN, and multivariable logistic regression was 0.15, 0.19, 0.18, 0.19, and 0.16, respectively. The RF model outperformed multivariable logistic regression model, SOFA score (AUROC 0.74), SAP II score (AUROC 0.77), and Charlson score (AUROC 0.69). Conclusion: The ML prediction model using RF algorithm provided the highest predictive performance for hospital mortality among ICU patient with lactic acidosis.
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14
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Wang S, Wang D, Huang X, Wang H, Le S, Zhang J, Du X. Development and validation of a nomogram model for early postoperative hyperlactatemia in patients undergoing cardiac surgery. J Thorac Dis 2021; 13:5395-5408. [PMID: 34659806 PMCID: PMC8482329 DOI: 10.21037/jtd-21-1004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/13/2021] [Indexed: 12/17/2022]
Abstract
Background Postoperative hyperlactatemia (POHL) is common in patients undergoing cardiac surgery, associated with adverse outcomes. The aim of this study was to identify predictors for POHL after cardiac surgery and to develop and validate a predictive model. Methods Adult patients who underwent open heart surgery at our institution between 2016 and 2019 were retrospectively included. The patients were randomly divided into training and validation groups at a 2:1 ratio. Multivariate logistic regression was performed to identify independent predictors for POHL in the training set. A nomogram was then constructed and was validated in the validation set. Results POHL developed in 713 of the 5,323 patients (13.4%). The mortality rate was higher in patients with POHL compared with patients without that (9.5% vs. 2.1%, P<0.001). Age, white blood cell (WBC) count, left ventricular ejection fraction, renal insufficiency, cardiac surgery history, red blood cell (RBC) transfusion, and cardiopulmonary bypass (CPB) time were identified as independent risk factors. The nomogram based on these predictors indicated good discrimination in both the training (c-index: 0.787) and validation (c-index: 0.820) sets. The calibration was reasonable by both visual inspection and goodness-of-fit test. The decision and clinical impact curves demonstrated good clinical utility. Conclusions We identified 7 independent risk factors and derived a prediction model for POHL in patients undergoing cardiac surgery. The model may contribute significantly to early risk assessment and clinical intervention.
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Affiliation(s)
- Su Wang
- Department of Emergency Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dashuai Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaofan Huang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongfei Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sheng Le
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jinnong Zhang
- Department of Emergency Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinling Du
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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15
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Sauer CM, Gómez J, Botella MR, Ziehr DR, Oldham WM, Gavidia G, Rodríguez A, Elbers P, Girbes A, Bodi M, Celi LA. Understanding critically ill sepsis patients with normal serum lactate levels: results from U.S. and European ICU cohorts. Sci Rep 2021; 11:20076. [PMID: 34625640 PMCID: PMC8501011 DOI: 10.1038/s41598-021-99581-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 09/24/2021] [Indexed: 12/13/2022] Open
Abstract
While serum lactate level is a predictor of poor clinical outcomes among critically ill patients with sepsis, many have normal serum lactate. A better understanding of this discordance may help differentiate sepsis phenotypes and offer clues to sepsis pathophysiology. Three intensive care unit datasets were utilized. Adult sepsis patients in the highest quartile of illness severity scores were identified. Logistic regression, random forests, and partial least square models were built for each data set. Features differentiating patients with normal/high serum lactate on day 1 were reported. To exclude that differences between the groups were due to potential confounding by pre-resuscitation hyperlactatemia, the analyses were repeated for day 2. Of 4861 patients included, 47% had normal lactate levels. Patients with normal serum lactate levels had lower 28-day mortality rates than those with high lactate levels (17% versus 40%) despite comparable physiologic phenotypes. While performance varied between datasets, logistic regression consistently performed best (area under the receiver operator curve 87–99%). The variables most strongly associated with normal serum lactate were serum bicarbonate, chloride, and pulmonary disease, while serum sodium, AST and liver disease were associated with high serum lactate. Future studies should confirm these findings and establish the underlying pathophysiological mechanisms, thus disentangling association and causation.
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Affiliation(s)
- Christopher M Sauer
- Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.,Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Institute for Infection and Immunity (AII), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Josep Gómez
- Department of Intensive Care Medicine, University Hospital of Tarragona Joan XXIII, Dr. Mallafrè Guasch 4, 43005, Tarragona, Spain. .,Pere Virgili Institute, Tarragona, Spain.
| | - Manuel Ruiz Botella
- Department of Intensive Care Medicine, University Hospital of Tarragona Joan XXIII, Dr. Mallafrè Guasch 4, 43005, Tarragona, Spain.,Pere Virgili Institute, Tarragona, Spain
| | - David R Ziehr
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - William M Oldham
- Harvard Medical School, Boston, MA, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Giovana Gavidia
- Department of e-Health, Eurecat, Technological Center of Catalonia, Barcelona, Spain
| | - Alejandro Rodríguez
- Department of Intensive Care Medicine, University Hospital of Tarragona Joan XXIII, Dr. Mallafrè Guasch 4, 43005, Tarragona, Spain.,Pere Virgili Institute, Tarragona, Spain
| | - Paul Elbers
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Institute for Infection and Immunity (AII), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Armand Girbes
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Institute for Infection and Immunity (AII), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Maria Bodi
- Department of Intensive Care Medicine, University Hospital of Tarragona Joan XXIII, Dr. Mallafrè Guasch 4, 43005, Tarragona, Spain.,Pere Virgili Institute, Tarragona, Spain
| | - Leo Anthony Celi
- Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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16
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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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17
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Ibrahim A, Bayramoglu B, Hokenek NM, Tekyol D. Lactate clearance during the first 2 hours after hospital admission: A useful biomarker for predicting 30-day mortality in patients with diabetic ketoacidosis. Int J Clin Pract 2021; 75:e14204. [PMID: 33811737 DOI: 10.1111/ijcp.14204] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/31/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE This study assessed whether lactate clearance (LC) during the first 2 hours after admission to the emergency department can be used to predict the 30-day mortality of patients diagnosed with diabetic ketoacidosis (DKA). MATERIAL AND METHODS This was a retrospective observational cohort study of patients admitted to the hospital between January 2014 and January 2019. We identified patients with diabetes who had blood gas test results at the time of admission and 2 hours thereafter. We then calculated the LC in these patients. Patients were divided into groups based on mortality and length of stay (LOS). The groups were compared in terms of age, blood gas pH, osmolarity, glucose level, lactate level on admission and 2 hours thereafter, LC, and bicarbonate (HCO3 - ), blood urea nitrogen, sodium, and potassium levels. RESULTS The overall mortality rate was 7.54% (8/107). Age, pH, osmolarity, the HCO3 - , and sodium levels, the lactate level 2 hours after admission, and LC differed significantly between the groups (Mann-Whitney U test, P < .05). LC cut-off values and areas under the curve were significant (P < .05). Receiver operating characteristic analysis indicated an LC cut-off value of 18.6441; the area under the curve was 0.711 (P < .05). CONCLUSIONS LC during the first 2 hours after admission is useful for predicting 30-day mortality in patients with diabetic ketoacidosis.
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Affiliation(s)
- Abdullah Ibrahim
- Department of Emergency Medicine, University of Health Sciences, Haydarpaşa Numune Training And Research Hospital, Istanbul, Turkey
| | - Burcu Bayramoglu
- Department of Emergency Medicine, Akcaabat Hackali Baba State Hospital, Trabzon, Turkey
| | - Nihat Mujdat Hokenek
- Department of Emergency Medicine, University of Health Sciences, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Turkey
| | - Davut Tekyol
- Department of Emergency Medicine, University of Health Sciences, Haydarpaşa Numune Training And Research Hospital, Istanbul, Turkey
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18
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Castel T, Theron M, Pichavant‐Rafini K, Guernec A, Joublin‐Delavat A, Gueguen B, Leon K. Can selenium-enriched spirulina supplementation ameliorate sepsis outcomes in selenium-deficient animals? Physiol Rep 2021; 9:e14933. [PMID: 34288548 PMCID: PMC8290477 DOI: 10.14814/phy2.14933] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/30/2022] Open
Abstract
In intensive care units, sepsis is the first cause of death. In this pathology, inflammation and oxidative status play a crucial role in patient outcomes. Interestingly, 92% of septic patients exhibit low selenium plasma concentrations (a component of antioxidant enzymes). Moreover, Spirulina platensis, a blue-green algae, demonstrated anti-inflammatory effects. In this context, the main purpose of our study was to analyze the effect of a selenium-enriched spirulina after a selenium deficiency on sepsis outcome in rats. Sixty-four rats were fed 12 weeks with a selenium-deficient food. After 8 weeks, rats were supplemented (via drinking water) for 4 weeks with sodium selenite (Se), spirulina (Spi), or selenium-enriched spirulina (SeSp). Sepsis was then induced by cecal ligature and puncture, and survival duration was observed. The plasma selenium concentration was measured by ICPMS. Expression of GPx1 and GPx3 mRNA was measured by RT-PCR. Blood parameters (lactates and HCO3- concentrations, pH, PO2 , and PCO2 ) were analyzed at 0, 1, and 2 h as well as inflammatory cytokines (IL-6, TNF-α, IL-10). Sodium selenite and SeSP supplementations restored plasma selenium concentration prior to sepsis. The survival duration of SeSP septic rats was significantly lower than that of selenium-supplemented ones. Gpx1 mRNA was increased after a selenium-enriched spirulina supplementation while Gpx3 mRNA levels remained unchanged. Furthermore, sodium selenite prevented sepsis-induced acidosis. Our results show that on a basis of a Se deficiency, selenium-enriched spirulina supplementations significantly worsen sepsis outcome when compared to Se supplementation. Furthermore, Se supplementation but not selenium-enriched spirulina supplementation decreased inflammation and restored acid-base equilibrium after a sepsis induction.
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Affiliation(s)
- Thomas Castel
- Université de BrestEA 4324 ORPHYUFR Sciences et TechniquesBrestFrance
| | - Michaël Theron
- Université de BrestEA 4324 ORPHYUFR Sciences et TechniquesBrestFrance
| | | | - Anthony Guernec
- Université de BrestEA 4324 ORPHYUFR Sciences et TechniquesBrestFrance
| | | | - Bleuenn Gueguen
- CNRSUniv BrestUMS 3113PlouzanéFrance
- UMR 6538Laboratoire Géosciences OcéanCNRSUniv BrestPlouzanéFrance
| | - Karelle Leon
- Université de BrestEA 4324 ORPHYUFR Sciences et TechniquesBrestFrance
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19
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Abstract
Lactic acidosis occurs commonly and can be a marker of significant physiologic derangements. However what an elevated lactate level and acidemia connotes and what should be done about it is subject to inconsistent interpretations. This review examines the varied etiologies of lactic acidosis, the physiologic consequences, and the known effects of its treatment with sodium bicarbonate. Lactic acidosis is often assumed to be a marker of hypoperfusion, but it can also result from medications, organ dysfunction, and sepsis even in the absence of malperfusion. Acidemia causes deleterious effects in almost every organ system, but it can also have positive effects, increasing localized blood flow and oxygen delivery, as well as providing protection against hypoxic cellular injury. The use of sodium bicarbonate to correct severe acidemia may be tempting to clinicians, but previous studies have failed to show improved patient outcomes following bicarbonate administration. Bicarbonate use is known to decrease vasomotor tone, decrease myocardial contractility, and induce intracellular acidosis. This suggests that mild to moderate acidemia does not require correction. Most recently, a randomized control trial found a survival benefit in a subgroup of critically ill patients with serum pH levels <7.2 with concomitant acute kidney injury. There is no known benefit of correcting serum pH levels ≥ 7.2, and sparse evidence supports bicarbonate use <7.2. If administered, bicarbonate is best given as a slow IV infusion in the setting of adequate ventilation and calcium replacement to mitigate its untoward effects.
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20
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Stefansson JS, Christensen R, Ottosen CI, Rasmussen LS. Measurements of Cardiac Output and Management of Blood Transfusions During Burn Surgery-An Observational Prospective Study. J Burn Care Res 2021; 42:420-424. [PMID: 33022033 DOI: 10.1093/jbcr/iraa166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Burn surgery can cause extensive bleeding, which lead to perioperative blood transfusions. The purpose of this study was to investigate whether blood transfusions during burn surgery, guided by standard monitoring with inspection of the operative field, measurements of blood pressure, heart rate, hourly diuresis, and concentrations of hemoglobin and lactate could sustain the preoperative cardiac output (CO) till end of surgery. We investigated 15 patients ≥18 years of age scheduled for burn surgery, where the perioperative monitoring included an arterial line. After induction of anesthesia and before start of surgery, we measured baseline values of CO with the minimally invasive LiDCOrapid, mean arterial pressure, and concentrations of hemoglobin and lactate in arterial blood. We measured these values every 30 minutes through surgery. The primary outcome was change in CO from baseline till end of surgery. Secondary outcomes included the change in concentrations of hemoglobin and lactate from baseline till end of surgery. We found no statistically significant change in CO from baseline till end of surgery (6.6 [±2.4] liters/min; 7.2 [±3.2] liters/min; P = .26). We found a statistically significant decrease in concentration of hemoglobin (7.2 [±0.8] mmol/liter; 6.2 [±0.9] mmol/liter; P = .0002), and a statistically significant increase in concentration of lactate (1.3 [±0.5] mmol/liter; 1.7 [±1] mmol/liter; P = .02). The perioperative blood transfusion guided by standard monitoring seemed to sustain CO from baseline till end of surgery; however, further research is needed to confirm this.
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Affiliation(s)
| | - Rasmus Christensen
- Department of Anaesthesia, Center of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Camilla Ikast Ottosen
- Department of Anaesthesia, Center of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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22
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Fernandes D, Pacheco LK, Sordi R, Scheschowitsch K, Ramos GC, Assreuy J. Angiotensin II receptor type 1 blockade improves hyporesponsiveness to vasopressors in septic shock. Eur J Pharmacol 2021; 897:173953. [PMID: 33617825 DOI: 10.1016/j.ejphar.2021.173953] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 02/04/2021] [Accepted: 02/15/2021] [Indexed: 11/30/2022]
Abstract
Sepsis activates the renin-angiotensin system and the production of angiotensin II, which has a key role in the regulation of blood pressure through AT1 receptors. However, excessive activation of AT1 receptor is associated with deleterious effects. We investigated the consequences of a differential blockade of AT1 receptor caused by two doses of losartan (0.25 mg/kg or 15 mg/kg, s.c), a selective AT1 receptor antagonist on sepsis outcome. These doses reduced the effect of angiotensin II in normal rats by 30% and >90% 8 h after administration, respectively, but only the higher dose maintained its inhibitory effect (~70%) 24 h after injection. Sepsis was induced by cecal ligation and puncture (CLP). Losartan was injected 2 h after CLP and parameters were evaluated 6 and 24 h after CLP. Septic rats developed hypotension and hyporesponsiveness to vasoconstrictors, an intense inflammatory process and increase in plasma markers of organ dysfunction. The lower dose of losartan improved the vasoconstrictive response to phenylephrine and angiotensin II, reduced lung myeloperoxidase and prevented leukopenia 24 h after CLP, but it did not reduce NOS-2 expression, plasma IL-6 levels or organ injury parameters of septic rats. On the other hand, the higher dose of losartan worsened the response to vasoconstrictors, potentiated the hypotension and increased further levels of creatine, urea and lactate in septic rats. Therefore, an early and partial blockade of AT1 receptor with a low dose of losartan may counteract sepsis-induced refractoriness to vasoconstrictors thus providing an opportunity to improve the outcome of this condition.
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MESH Headings
- Angiotensin II/metabolism
- Angiotensin II Type 1 Receptor Blockers/pharmacology
- Animals
- Arterial Pressure/drug effects
- Disease Models, Animal
- Dose-Response Relationship, Drug
- Female
- Hypotension/drug therapy
- Hypotension/metabolism
- Hypotension/microbiology
- Hypotension/physiopathology
- Inflammation Mediators/blood
- Losartan/pharmacology
- Rats, Wistar
- Receptor, Angiotensin, Type 2/drug effects
- Receptor, Angiotensin, Type 2/metabolism
- Renin-Angiotensin System/drug effects
- Shock, Septic/drug therapy
- Shock, Septic/metabolism
- Shock, Septic/microbiology
- Shock, Septic/physiopathology
- Vasoconstriction/drug effects
- Vasoconstrictor Agents/pharmacology
- Rats
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Affiliation(s)
- Daniel Fernandes
- Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Letícia Kramer Pacheco
- Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Regina Sordi
- Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Karin Scheschowitsch
- Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Gustavo Campos Ramos
- Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Jamil Assreuy
- Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, Brazil.
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23
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Significance of lactate clearance in septic shock patients with high bilirubin levels. Sci Rep 2021; 11:6313. [PMID: 33737668 PMCID: PMC7973422 DOI: 10.1038/s41598-021-85700-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 02/25/2021] [Indexed: 12/29/2022] Open
Abstract
Lactate clearance is affected by hepatic function. However, it is unclear whether the association between hepatic dysfunction and lactate clearance can act as a prognostic marker of clinical outcomes in patients with septic shock. We aimed to evaluate the association between lactate clearance and mortality in two cohorts of septic shock patient who had hepatic dysfunction based on their total serum bilirubin levels (TBIL). Lactate clearance at 24 h after the onset of septic shock was analyzed using two cohorts, sub-categorized into two groups based on TBIL: < 2 mg/dL and ≥ 2 mg/dL. In the derivation cohort, lactate clearance was lower in non-survivors than in survivors with TBIL ≥ 2 mg/dL, while there was no significant difference in lactate clearance between non-survivors and survivors with TBIL < 2 mg/dL. Multivariate logistic regression analysis revealed that increased lactate clearance was significantly associated with decreased 28-day mortality in the TBIL ≥ 2 mg/dL group (10% lactate clearance, adjusted odds ratio [OR]: 0.88, 95% confidence interval (CI): 0.80-0.97, P = 0.0075), Creatinine level ≥ 2 mg/dL group (adjusted OR: 0.88, 95% CI: 0.81-0.95, P = 0.00069) and APACHE II score ≥ 35 group (adjusted OR: 0.93, 95% CI: 0.87-0.98, P = 0.013). In the validation cohort, lactate clearance was lower in non-survivors than in survivors with TBIL ≥ 2 mg/dL, while no significant difference in lactate clearance was observed between non-survivors and survivors with TBIL < 2 mg/dL. Increased lactate clearance was significantly associated with decreased 28-day mortality in the TBIL ≥ 2 mg/dL group (10% lactate clearance, adjusted OR: 0.89, 95% CI: 0.83-0.96, P = 0.0038) and the association was just about significant in APACHE II score ≥ 35 group (adjusted OR: 0.86, 95% CI: 0.74-1.00, P = 0.051). In conclusion, increased lactate clearance in septic shock patients with hepatic dysfunction (TBIL ≥ 2 mg/dL) or high severity (APACHE II score ≥ 35) was associated with decreased 28-day mortality.
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Borah P, Saloi DK, Deka A, Hazarika R, Konwar R, Mahanta P, Kalita D, Phukan C, Das K. Assessment of the Clinical Interpreter of Death in Life-Threatening Infective Cases Admitted in the Intensive Care Unit of a North-Eastern State of India. Cureus 2021; 13:e13915. [PMID: 33747664 PMCID: PMC7962036 DOI: 10.7759/cureus.13915] [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] [Indexed: 11/24/2022] Open
Abstract
Objectives The clinical factors affecting a patient's condition monitored over time could be useful not only to decide on an intervention that may increase the patients' possibilities of survival but also to predict the treatment outcome. Therefore, this study evaluates the clinical factors as predictors of mortality among severe sepsis patients admitted in the intensive care unit (ICU) of a tertiary care center. Method We did a prospective study on over 50 life-threatening infective cases with different causes admitted in the ICU. Clinical and biochemical parameters like temperature, heart rate, blood pressure, bicarbonate levels, blood lactate levels, and pH were monitored at admission, after 24 hours, and after 72 hours. The statistical analysis was done using Microsoft Excel (Microsoft Corporation, Redmond, WA) and the Statistical Package for the Social Studies (SPSS) version 22 (IBM Corp., Armonk, NY). We have obtained ethical clearance from the ethics committee (human) of Assam Medical College and Hospital, Dibrugarh. Before the collection of the data, we also took informed consent from the participants. Results The mean age of non-survivors was 44.35±11.64 years and that of survivors was 36.60±9.28 years, and the difference was statistically significant (p-value <0.003). An analysis of values of the various vital signs indicated substantial differences in the mean at different time intervals among survivors and non-survivors (p-value <0.05). Among non-survivors, mean temperature, pulse, and rate of respiration were observed to increase over time while blood pressure and oxygen saturation levels were significantly decreasing. Compared to survivors, the mean lactate levels of non-survivors at different time intervals were statistically significant (p-value <0.05). It is also observed that the pH of non-survivors was lower than survivors, and the mean pH value significantly different at different time intervals among the two groups (p-value <0.05). Conclusion The temperature, pulse, rate of respiration, blood pressure, and oxygen saturation levels are essential determinants of patient mortality in those suffering from a severe infection, besides serial lactate levels, bi-carbonate levels, and pH levels.
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Affiliation(s)
- Pollov Borah
- Anaesthesiology, Jorhat Medical College and Hospital, Jorhat, IND
| | - Dilip K Saloi
- Anaesthesiology, Jorhat Medical College and Hospital, Jorhat, IND
| | - Amarendra Deka
- Anaesthesiology, Assam Medical College and Hospital, Dibrugarh, IND
| | - Rajib Hazarika
- Anaesthesiology, Jorhat Medical College and Hospital, Jorhat, IND
| | - Ranjumoni Konwar
- Radiology, Fakhruddin Ali Ahmed Medical College (FAAMC) and Hospital, Barpeta, IND
| | - Putul Mahanta
- Forensic Medicine and Toxicology, Assam Medical College and Hospital, Dibrugarh, IND
| | - Deepjyoti Kalita
- Microbiology, All India Institute of Medical Sciences, Rishikesh, IND
| | | | - Kahua Das
- Physiology, Tezpur Medical College and Hospital, Tezpur, IND
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Gharipour A, Razavi R, Gharipour M, Modarres R, Nezafati P, Mirkheshti N. The incidence and outcome of severe hyperlactatemia in critically ill patients. Intern Emerg Med 2021; 16:115-123. [PMID: 32415561 DOI: 10.1007/s11739-020-02337-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 04/06/2020] [Indexed: 12/22/2022]
Abstract
This study aimed to assess the incidence, persistence, and associated mortality of severe hyperlactatemia in a large cohort of unselected critically ill patients. Also, we evaluated the association between 12 h lactate clearance, the timing of severe hyperlactatemia, and the maximum lactate levels with ICU mortality. In this retrospective, single-center study, we used data from the Multiparameter Intelligent Monitoring in Intensive Care III (MIMIC-III) database. Data extracted to screen 23,598 ICU patients for severe hyperlactatemia. A total of 23,598 critically ill patients were eligible for this study. Overall, ICU mortality in the 23,598 ICU patients was 12.1%. Of these, 760 patients had lactate concentration [Formula: see text] 10 mmol/L and ICU mortality in this group was 65%. Our findings confirm the association between hyperlactatemia and ICU mortality [odds ratio 1.42 (95% CI 1.35; 1.49; P < 0.001)]. Data for 12 h lactate clearance was available for 443 patients (276 nonsurvivable vs. 167 survival). 12 h lactate clearance yielded a high area under the curve (AUC) of 0.78, (95% CI 0.74 and 0.83). Severe hyperlactatemia is associated with extremely high ICU mortality in a heterogeneous ICU population. Lactate derived variables (the timing and persistence of severe hyperlactatemia, maximum level, and 12 h clearance) are shown to be associated with ICU mortality in patients with severe hyperlactatemia. Our results suggest that maximum lactate level and 12 h lactate clearance were clinically useful prognostic parameters for patients with severe hyperlactatemia.
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Affiliation(s)
- Amin Gharipour
- Business School, Griffith University, Gold Coast Campus, Australia
| | - Rouzbeh Razavi
- Department of Management and Information Systems, Kent State University, Kent, OH, USA
| | - Mojgan Gharipour
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Esfahan, Iran.
| | - Reza Modarres
- School of Medical Sciences, Griffith University, Gold Coast Campus, Australia
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Stefanovski D, Wilkins PA, Boston RC. Modeling Challenge Data to Quantify Endogenous Lactate Production. Front Endocrinol (Lausanne) 2021; 12:656054. [PMID: 34267726 PMCID: PMC8277460 DOI: 10.3389/fendo.2021.656054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 06/07/2021] [Indexed: 11/13/2022] Open
Abstract
With the intention of isolating the susceptibility of modeling methodology to influence our investigation of the infusion data, we used three kinetic approaches to our models: a simple approach, a unit approach, and a novel approach. The simple approach used exclusively built-in modeling features of the software in terms of units of the infusion dilution (mmol/L), as well as in terms of the precision of switching the infusion on and off. The unit approach used the same switching mechanism as the simple approach, but the units were modeled in those of the infusion (e.g., mmol/kg). Thirdly with the novel approach, we used an automated approach to controlling the infusion, in the sense that as the modeling mechanism sensed the slowdown of the infusion, it was gradually turned off. The units of the analysis for the novel approach were exactly the same as those deployed in the unit approach. Our objective here was to see if common pharmacokinetic parameters were seriously impacted by the particular modeling method.
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Affiliation(s)
- Darko Stefanovski
- Department of Clinical Studies – New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States
- *Correspondence: Darko Stefanovski,
| | - Pamela A. Wilkins
- Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Urbana-Champaign, IL, United States
| | - Raymond C. Boston
- Department of Clinical Studies- New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States
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Abstract
Lactic acidosis and hyperlactatemia are common metabolic disturbances in patients with severe malaria. Lactic acidosis causes physiological adverse effects, which can aggravate the outcome of malaria. Despite its clear association with mortality in malaria patients, the etiology of lactic acidosis is not completely understood. In this review, the possible contributors to lactic acidosis and hyperlactatemia in patients with malaria are discussed. Both increased lactate production and impaired lactate clearance may play a role in the pathogenesis of lactic acidosis. The increased lactate production is caused by several factors, including the metabolism of intraerythrocytic Plasmodium parasites, aerobic glycolysis by activated immune cells, and an increase in anaerobic glycolysis in hypoxic cells and tissues as a consequence of parasite sequestration and anemia. Impaired hepatic and renal lactate clearance, caused by underlying liver and kidney disease, might further aggravate hyperlactatemia. Multiple factors thus participate in the etiology of lactic acidosis in malaria, and further investigations are required to fully understand their relative contributions and the consequences of this major metabolic disturbance.
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Affiliation(s)
- Hendrik Possemiers
- Laboratory of Immunoparasitology, Department of Microbiology and Immunology, Rega Institute for Medical Research, KU Leuven, University of Leuven, Belgium
| | - Leen Vandermosten
- Laboratory of Immunoparasitology, Department of Microbiology and Immunology, Rega Institute for Medical Research, KU Leuven, University of Leuven, Belgium
| | - Philippe E. Van den Steen
- Laboratory of Immunoparasitology, Department of Microbiology and Immunology, Rega Institute for Medical Research, KU Leuven, University of Leuven, Belgium
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Siffring T, Prabhu N, Evans A, Dauch W, Smigla G, Kaemmer D. Sustained Total All-Region (STAR) Perfusion: An Optimized Perfusion Strategy for Norwood Reconstruction. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2020; 52:332-336. [PMID: 33343037 PMCID: PMC7728505 DOI: 10.1182/ject-2000038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/06/2020] [Indexed: 11/20/2022]
Abstract
Early iterations of the Norwood procedure used aortic cross-clamping, myocardial arrest, and, sometimes, deep hypothermic circulatory arrest. The resulting hypothermia and prolonged ischemia caused frequent cardiac, neurologic, renal, and other end-organ dysfunctions. Our group describes a novel technique, sustained total all-region (STAR) perfusion, which circumvents these issues by providing continuous perfusion to the head, heart, and coronaries at temperatures of 32-34°C. A single DLP® straight venous cannula (Medtronic, Minneapolis, MN) is placed in the right atrium, and a DLP® pediatric arterial cannula, with a high-flow stopcock attached, is placed in the ascending aorta or innominate artery to provide flow to the head. A cardioplegia needle with walrus tubing is connected to the stopcock to provide flow to the coronary arteries. For lower body perfusion, an olive tip cannula is placed into the descending aorta lumen and attached to the 1/8″ line from the cardioplegia system which provides warm arterial blood flow. STAR perfusion allows the Norwood procedure to be completed with mild hypothermia and continuous perfusion to all vascular beds with reduced cardiopulmonary bypass as well as total operative times. This technique is successfully achieved with minimal changes to circuitry, minor modifications to heart-lung machine servoregulation and few additional cannulation disposables.
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Affiliation(s)
- Travis Siffring
- Department of Perfusion Services, Duke University Hospital, Durham, North Carolina; and Duke University School of Medicine, Durham, North Carolina
| | - Neel Prabhu
- Department of Perfusion Services, Duke University Hospital, Durham, North Carolina; and Duke University School of Medicine, Durham, North Carolina
| | - Amy Evans
- Department of Perfusion Services, Duke University Hospital, Durham, North Carolina; and Duke University School of Medicine, Durham, North Carolina
| | - William Dauch
- Department of Perfusion Services, Duke University Hospital, Durham, North Carolina; and Duke University School of Medicine, Durham, North Carolina
| | - Gregory Smigla
- Department of Perfusion Services, Duke University Hospital, Durham, North Carolina; and Duke University School of Medicine, Durham, North Carolina
| | - David Kaemmer
- Department of Perfusion Services, Duke University Hospital, Durham, North Carolina; and Duke University School of Medicine, Durham, North Carolina
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Quantitative Assessment of Blood Lactate in Shock: Measure of Hypoxia or Beneficial Energy Source. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2608318. [PMID: 33150168 PMCID: PMC7603544 DOI: 10.1155/2020/2608318] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/18/2020] [Indexed: 12/16/2022]
Abstract
Blood lactate concentration predicts mortality in critically ill patients and is clinically used in the diagnosis, grading of severity, and monitoring response to therapy of septic shock. This paper summarizes available quantitative data to provide the first comprehensive description and critique of the accepted concepts of the physiology of lactate in health and shock, with particular emphasis on the controversy of whether lactate release is simply a manifestation of tissue hypoxia versus a purposeful transfer ("shuttle") of lactate between tissues. Basic issues discussed include (1) effect of nonproductive lactate-pyruvate exchange that artifactually enhances flux measurements obtained with labeled lactate, (2) heterogeneous tissue oxygen partial pressure (Krogh model) and potential for unrecognized hypoxia that exists in all tissues, and (3) pathophysiology that distinguishes septic from other forms of shock. Our analysis suggests that due to exchange artifacts, the turnover rate of lactate and the lactate clearance are only about 60% of the values of 1.05 mmol/min/70 kg and 1.5 L/min/70 kg, respectively, determined from the standard tracer kinetics. Lactate turnover reflects lactate release primarily from muscle, gut, adipose, and erythrocytes and uptake by the liver and kidney, primarily for the purpose of energy production (TCA cycle) while the remainder is used for gluconeogenesis (Cori cycle). The well-studied physiology of exercise-induced hyperlactatemia demonstrates massive release from the contracting muscle accompanied by an increased lactate clearance that may occur in recovering nonexercising muscle as well as the liver. The very limited data on lactate kinetics in shock patients suggests that hyperlactatemia reflects both decreased clearance and increased production, possibly primarily in the gut. Our analysis of available data in health and shock suggests that the conventional concept of tissue hypoxia can account for most blood lactate findings and there is no need to implicate a purposeful production of lactate for export to other organs.
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Oh CH, Kim JW, Kim GH, Lee KR, Hong DY, Park SO, Baek KJ, Kim SY. Serum Lactate Could Predict Mortality in Patients With Spontaneous Subarachnoid Hemorrhage in the Emergency Department. Front Neurol 2020; 11:975. [PMID: 33013645 PMCID: PMC7499023 DOI: 10.3389/fneur.2020.00975] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 07/27/2020] [Indexed: 01/28/2023] Open
Abstract
Background: Serum lactate is a useful biomarker for prediction of mortality in critically ill patients. The purpose of this study was to identify if serum lactate could be used as a biomarker for predicting mortality in patients with subarachnoid hemorrhage (SAH) in the emergency department. Methods: This retrospective study enrolled 189 patients. Baseline demographic data and clinical characteristics of patients were obtained from medical record review. Multiple logistic regression analysis was performed to determine predictor variables significantly associated with mortality. Receiver operating characteristic (ROC) curve analysis was used to evaluate the performance of variables for mortality prediction in SAH. Results: Using multivariate logistic regression analysis, age [OR 1.05; 95% confidence interval (CI) 1.00–1.10; p = 0.037], Hunt and Hess scale score (OR 3.29; 95% CI 1.62–6.70; p = 0.001), serum lactate level (OR 1.33; 95% CI 1.03–1.74; p = 0.032), and serum glucose level (OR 1.01; 95% CI 1.00–1.02; p = 0.049) predicted overall mortality in SAH. The area under the ROC curve (AUC) value for the use of serum lactate level to predict mortality in SAH was 0.815 (95% CI 0.753–0.868) (p < 0.001). Conclusion: Serum lactate may be a useful biomarker for the early prediction of mortality in SAH patients in the emergency department.
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Affiliation(s)
- Chang Hwan Oh
- Department of Emergency Medicine, Konkuk University Medical Center, School of Medicine, Konkuk University, Seoul, South Korea
| | - Jong Won Kim
- Department of Emergency Medicine, Konkuk University Medical Center, School of Medicine, Konkuk University, Seoul, South Korea.,Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, South Korea
| | - Geon Ha Kim
- Department of Neurology, College of Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans University, Seoul, South Korea
| | - Kyeong Ryong Lee
- Department of Emergency Medicine, Konkuk University Medical Center, School of Medicine, Konkuk University, Seoul, South Korea
| | - Dae Young Hong
- Department of Emergency Medicine, Konkuk University Medical Center, School of Medicine, Konkuk University, Seoul, South Korea
| | - Sang O Park
- Department of Emergency Medicine, Konkuk University Medical Center, School of Medicine, Konkuk University, Seoul, South Korea
| | - Kwang Je Baek
- Department of Emergency Medicine, Konkuk University Medical Center, School of Medicine, Konkuk University, Seoul, South Korea
| | - Sin Young Kim
- Department of Emergency Medicine, Konkuk University Medical Center, School of Medicine, Konkuk University, Seoul, South Korea
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Abstract
Cardiogenic shock (CS) is a life-threatening condition characterized by end-organ hypoperfusion and hypoxia primarily due to cardiac dysfunction and low cardiac output. Unfortunately, the mortality and morbidity associated with CS have remained high despite notable advances in heart failure management. Treatment should be carefully guided by hemodynamics assessment. Although inotropes, vasopressors, mechanical circulatory support, and catheter intervention for critical valve lesion are not always recommended, they are helpful in selected patients. Early diagnosis, accurate hemodynamic assessment, and prompt therapeutic intervention are crucial in the management of acute decompensated heart failure with CS.
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Affiliation(s)
- Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe 650-0047, Japan; Department of Clinical Research Support, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe 650-0047, Japan.
| | - Andrew Xanthopoulos
- Department of Cardiology, University General Hospital of Larissa, Larissa, Greece
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Prognosis Value of Early Veno Arterial PCO2 Difference in Patients Under Peripheral Veno Arterial Extracorporeal Membrane Oxygenation. Shock 2020; 54:744-750. [DOI: 10.1097/shk.0000000000001554] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Grip J, Falkenström T, Promsin P, Wernerman J, Norberg Å, Rooyackers O. Lactate kinetics in ICU patients using a bolus of 13C-labeled lactate. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:46. [PMID: 32041652 PMCID: PMC7011254 DOI: 10.1186/s13054-020-2753-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 01/27/2020] [Indexed: 12/25/2022]
Abstract
Background Plasma lactate concentrations and their trends over time are used for clinical prognosis, and to guide treatment, in critically ill patients. Although heavily relied upon for clinical decision-making, lactate kinetics of these patients is sparsely studied. Aim To establish and validate a feasible method to study lactate kinetics in critically ill patients. Methods Healthy volunteers (n = 6) received a bolus dose of 13C-labeled lactate (20 μmol/kg body weight), and 43 blood samples were drawn over 2 h to determine the decay in labeled lactate. Data was analyzed using non-compartmental modeling calculating rates of appearance (Ra) and clearance of lactate. The area under the curve (AUC) was calculated using a linear-up log-down trapezoidal approach with extrapolation beyond 120 min using the terminal slope to obtain the whole AUC. After evaluation, the same protocol was used in an unselected group of critically ill patients (n = 10). Results Ra for healthy volunteers and ICU patients were 12.8 ± 3.9 vs 22.7 ± 11.1 μmol/kg/min and metabolic clearance 1.56 ± 0.39 vs 1.12 ± 0.43 L/min, respectively. ICU patients with normal lactate concentrations showed kinetics very similar to healthy volunteers. Simulations showed that reducing the number of samples from 43 to 14 gave the same results. Our protocol yielded results on lactate kinetics very similar to previously published data using other techniques. Conclusion This simple and user-friendly protocol using an isotopically labeled bolus dose of lactate was accurate and feasible for studying lactate kinetics in critically ill ICU patients. Trial registration ANZCTR, ACTRN12617000626369, registered 8 March 2017. https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372507&isReview=true
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Affiliation(s)
- Jonathan Grip
- Clinical Science Intervention and Technology (CLINTEC), Department of Anesthesiology and Intensive Care, Karolinska Inititutet, Huddinge, Sweden. .,Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden.
| | - Tobias Falkenström
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden
| | - Panuwat Promsin
- Clinical Science Intervention and Technology (CLINTEC), Department of Anesthesiology and Intensive Care, Karolinska Inititutet, Huddinge, Sweden.,Division of Critical Care, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jan Wernerman
- Clinical Science Intervention and Technology (CLINTEC), Department of Anesthesiology and Intensive Care, Karolinska Inititutet, Huddinge, Sweden.,Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden
| | - Åke Norberg
- Clinical Science Intervention and Technology (CLINTEC), Department of Anesthesiology and Intensive Care, Karolinska Inititutet, Huddinge, Sweden.,Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden
| | - Olav Rooyackers
- Clinical Science Intervention and Technology (CLINTEC), Department of Anesthesiology and Intensive Care, Karolinska Inititutet, Huddinge, Sweden.,Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden
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Heming N, Salah A, Meng P, Sivanandamoorthy S, Bounab R, Chevret S, Annane D. Thiamine status and lactate concentration in sepsis: A prospective observational study. Medicine (Baltimore) 2020; 99:e18894. [PMID: 32049788 PMCID: PMC7035069 DOI: 10.1097/md.0000000000018894] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Thiamine is an essential co-factor for aerobic metabolism. Both thiamine deficiency and sepsis may be associated with hyperlactatemia and hypotension. We assessed the relationship between thiamine compounds, lactate concentrations and clinical outcomes in septic patients.We undertook a prospective observational single-center study. Erythrocyte levels of total thiamine, free thiamine, thiamine mono, di and triphosphate (TMP, TDP, and TTP respectively), the erythrocyte transketolase activity (ETKA) and the effect of thiamine diphosphate on ETKA were measured in septic patients by high performance liquid chromatography and correlated with arterial lactate. Vital status at the end of intensive care unit stay was recorded.Overall, 28 patients suffering from sepsis were included. Median (interquartile range [IQR]) age was 60 [44-77.3] years, 15 (53.6%) patients were male, median [IQR] simplified acute physiology score II was 40 [27-50]. There was no correlation between total thiamine and lactate levels (P = .33). There was no correlation between free thiamine (P = .81), TMP (P = .71), TDP (P = .31), TTP (P = .86), and lactate levels in our population. There was no correlation between ETKA (P = .58) or the effect of TDP on ETKA (P = .40) and lactate concentration. Total thiamine and TDP concentration were significantly higher in intensive care unit (ICU) survivors than in nonsurvivors (P = .03 and P = .03). The effect of TDP on ETKA was significantly higher in nonsurvivors compared to survivors (P = .04).We found no correlation between thiamine compounds and lactate concentration in sepsis. Thiamine deficiency in sepsis may be associated with ICU-mortality.
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Affiliation(s)
- Nicholas Heming
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France and U1173 Lab Inflammation & Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-Le-Bretonneux
| | - Amor Salah
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches
| | - Paris Meng
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches
| | | | - Rania Bounab
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches
| | - Sylvie Chevret
- Biostatistical Unit, Saint Louis Hospital, Paris, France
| | - Djillali Annane
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France and U1173 Lab Inflammation & Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-Le-Bretonneux
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Chan JZW, Tan JH, Lather KS, Ng AJY, Ong Z, Zou X, Chua MT, Kuan WS. Beta-blockers' effect on Levels of Lactate in patients with suspected sepsis - The BeLLa study. Am J Emerg Med 2019; 38:2574-2579. [PMID: 31902697 DOI: 10.1016/j.ajem.2019.12.046] [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] [Received: 11/02/2019] [Revised: 12/02/2019] [Accepted: 12/23/2019] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE In the assessment and management of septic patients in the emergency department (ED), serum lactate is often measured to stratify severity to guide decision making. Increased adrenergic drive has been postulated as a contributory factor for hyperlactatemia in sepsis. We aim to prospectively evaluate the effect of chronic beta-blocker use on serum lactate levels in sepsis at initial presentation to the ED. METHODS We conducted a prospective observational study at the ED of a tertiary care academic medical center in Singapore. One hundred and ninety-five ED patients who fulfilled all of the following: (1) age 45 years and above, (2) tympanic temperature ≥ 37.8 °C or clinically suspected to have an infection, and (3) quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) score ≥ 1 were included in the study. Serum venous lactate was sampled within two hours from presentation to the ED. The primary outcome measure was the difference in initial serum venous lactate concentration at presentation to the ED in patients on chronic beta-blockers versus patients without. RESULTS Seventy patients (35.9%) were on long-term beta-blocker therapy. The primary outcome of mean initial serum venous lactate concentration was similar between patients prescribed chronic beta-blocker therapy and patients without (1.78 mmol/L versus 1.70 mmol/L, p = .540). Chronic beta-blocker therapy also did not significantly affect mean initial serum venous lactate concentration across all subgroups of sepsis risk stratification. CONCLUSIONS Long-term beta-blocker therapy did not significantly affect initial serum venous lactate concentration in ED patients with suspected sepsis.
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Affiliation(s)
- Jonathan Zhao Wang Chan
- Department of Emergency Medicine, Woodlands Health Campus, National Healthcare Group, Singapore
| | | | - Kanwar Sudhir Lather
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Alexander Jet Yue Ng
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore
| | | | - Xiangyu Zou
- Ministry of Health Holdings Pte Ltd, Singapore
| | - Mui Teng Chua
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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37
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Hochrainer M, Funk GC. [Interpretation of acid-base disorders]. Med Klin Intensivmed Notfmed 2019; 114:765-776. [PMID: 31641791 DOI: 10.1007/s00063-019-00621-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/23/2019] [Accepted: 08/29/2019] [Indexed: 11/26/2022]
Abstract
Keeping blood pH levels stable within narrow limits is prerequisite for maintaining normal body function. Disruptions of this equilibrium can occur for a variety of reasons and may result in life-threatening conditions. Therefore, the identification and the interpretation of acid-base disorders are of great importance in emergency medicine. The same applies to intensive care as well as to almost all areas of internal medicine. In this article, we provide a practical overview of all relevant acid-base disorders that are due to both metabolic and respiratory disturbances. In addition, it shows how they can be diagnosed in everyday clinical practice by applying the simplified Stewart Approach.
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Affiliation(s)
- Mathis Hochrainer
- Abteilung für Innere Medizin und Pneumologie, Krankenhaus Nord - Klinik Floridsdorf, Brünner Str. 68, 1210, Wien, Österreich.
- Karl Landsteiner Institut für Lungenforschung und Pneumologische Onkologie, Wien, Österreich.
| | - Georg-Christian Funk
- Medizinische Abteilung mit Pneumologie, Wilhelminenspital, Wien, Österreich
- Karl Landsteiner Institut für Lungenforschung und Pneumologische Onkologie, Wien, Österreich
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Bisarya R, Shaath D, Pirzad A, Satterwhite L, He J, Simpson SQ. Serum lactate poorly predicts central venous oxygen saturation in critically ill patients: a retrospective cohort study. J Intensive Care 2019; 7:47. [PMID: 31516712 PMCID: PMC6728973 DOI: 10.1186/s40560-019-0401-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 08/27/2019] [Indexed: 02/06/2023] Open
Abstract
Background Serum lactate and central venous oxygen saturation (ScvO2) are commonly used and commonly recommended as markers of tissue oxygenation in shock states. Medical literature has both explicitly stated and implied that the two biomarkers are interchangeable in the management of patients with shock. However, there have been relatively few direct comparisons of these tests in clinical circumstances, and the relationship between them is uncertain. The objective of our study was to evaluate whether simultaneous or near-simultaneous measurements of lactate and ScvO2 reveal a consistent relationship between these two biomarkers. Methods A retrospective cohort study was conducted in an urban, academic US hospital. All adults in ICUs between March 2007 and March 2017 who had a lactate measurement and ScvO2 or mixed venous oxygen saturation (SvO2) measurement made +/− 1 h from the lactate were included. Linear and non-linear correlations of ScvO2 and lactate were assessed in a variety of shock states. Results Two thousand sixty-two patients were included. Lactate and ScvO2 correlated poorly (r2 = 0.0041, p = 0.0019). This was true for patients with ScvO2 ≤ 65% (r2 = 0.0431, p < 0.001), patients with normal kidney and liver function (r2 = 0.0517, p < 0.001), and septic shock patients (r2 = 0.0037, p = 0.17). For patients with an O2 extraction ratio ≥ 50%, lactate and ScvO2 were strongly correlated (r2 = 0.93, p = 0.0019), but these patients represented only 2.8% of patients in whom the ratio could be calculated. Conclusions Lactate can predict ScvO2 when patients are at or below the critical oxygen delivery threshold, but relatively few shock patients meet this criterion. In the overall population of critically ill patients, serum lactate predicts ScvO2 poorly, even after controlling for factors that may affect lactate production. Lactate and ScvO2 should not be assumed to be interchangeable markers of tissue oxygenation/perfusion. Electronic supplementary material The online version of this article (10.1186/s40560-019-0401-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Roshan Bisarya
- 1School of Medicine, University of Kansas, Kansas City, KS USA
| | - Deena Shaath
- 1School of Medicine, University of Kansas, Kansas City, KS USA
| | - Arman Pirzad
- 2Department of Internal Medicine, University of Kansas, Kansas City, KS USA
| | - Lewis Satterwhite
- 3Division of Pulmonary and Critical Care Medicine, University of Kansas, 3901 Rainbow Boulevard, Mail Stop 3047, Kansas City, KS 66160 USA
| | - Jianghua He
- 4Department of Biostatistics, University of Kansas, Kansas City, KS USA
| | - Steven Q Simpson
- 3Division of Pulmonary and Critical Care Medicine, University of Kansas, 3901 Rainbow Boulevard, Mail Stop 3047, Kansas City, KS 66160 USA
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Villar J, Short JH, Lighthall G. Lactate Predicts Both Short- and Long-Term Mortality in Patients With and Without Sepsis. Infect Dis (Lond) 2019; 12:1178633719862776. [PMID: 31431799 PMCID: PMC6686323 DOI: 10.1177/1178633719862776] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 06/16/2019] [Indexed: 01/27/2023] Open
Abstract
Objective To measure the relationship between lactate and mortality in hospital inpatients. Main outcomes of interest were 3-day, 30-day, and 1-year all-cause mortality. Design Retrospective cohort study, October 2011 to September 2013. Setting University-affiliated US Veterans Affairs Hospital. Patients All inpatients with lactate level measured during the study period. Measurements Analysis of peak lactate level (mmol/L) during the most recent admission for patients who died, and peak lactate level during an admission for surviving patients. Covariates including sepsis, ICU admission, code blue and rapid response calls, medical vs surgical ward, liver disease, kidney disease, and hospice status were recorded. Results In total, 3325 inpatients were included; 564 patients had sepsis. Median lactate 1.7 mmol/L (interquartile range [IQR] 1.2-2.6). The 3-day, 30-day, and 1-year mortality were 2.5%, 10%, and 24%, respectively. A lactate level cutoff of ⩾4 mmol/L had best test characteristics (sensitivity 52.4%, specificity 91.4%) to predict increased 3-day mortality. Unadjusted risk ratio of death in 3 days for lactate ⩾4 was 10.3 (95% confidence interval [CI] 6.8-15.7). Patients with sepsis had a consistently higher risk of death compared with patients without sepsis for any given level of lactate. Adjusted odds ratio (OR) of 3-day mortality for lactate ⩾4 was 7.6 (95% CI 4.6-12.5); 30-day mortality was 2.6 (95% CI 1.9-3.6); and 1-year mortality was 1.8 (95% CI 1.4-2.6). Lactates in the normal range (<1.7) were also independently associated with 30-day and 1-year mortality. Conclusions Lactate predicts risk of death in all patients, although patients with sepsis have a higher mortality for any given lactate level. We report the novel finding that serum lactate, including normal values, is associated with long-term mortality.
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Affiliation(s)
- Julian Villar
- Department of Internal Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jack H Short
- Department of Internal Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Geoffrey Lighthall
- Department of Anesthesia, Pain and Perioperative Medicine, Stanford University School of Medicine, Stanford, CA, USA
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40
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Nassar B, Mallat J. CO 2-derived variables for hemodynamic management in critically ill patients. J Thorac Dis 2019; 11:S1525-S1527. [PMID: 31388456 DOI: 10.21037/jtd.2019.04.94] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Boulos Nassar
- Department of Critical Care Medicine, Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE.,University of Iowa Hospitals and Clinics, Pulmonary and Critical Care Division, Iowa City, USA
| | - Jihad Mallat
- Department of Critical Care Medicine, Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
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He H, Long Y, Liu D, Tang B, Ince C. Relationship of relevant factors to P(v-a)CO 2/C(a-v)O 2 ratio in critically ill patients. J Int Med Res 2019; 48:300060519854633. [PMID: 31256730 PMCID: PMC7140220 DOI: 10.1177/0300060519854633] [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] [Indexed: 11/23/2022] Open
Abstract
Objective This study investigated the factors related to the ratio of the
venoarterial carbon dioxide tension difference
[P(v-a)CO2] to the arteriovenous oxygen content
difference [C(a-v)O2] (hereafter termed “Ratio”). Methods We retrospectively studied 1294 pairs of arterial and central
venous blood gas measurements in 352 critically ill patients. A
high Ratio was defined as > 1.68 based on published
literature. Measurements were divided into four groups: Group I
[P(v-a)CO2 ≤ 6 mmHg/central venous oxygen
saturation (ScvO2) < 70%], Group II
[P(v-a)CO2 ≤ 6 mmHg/ScvO2 ≥ 70%],
Group III [P(v-a)CO2 > 6
mmHg/ScvO2 ≥ 70%], and Group IV
[P(v-a)CO2 > 6
mmHg/ScvO2 < 70%]. Results The Ratio’s strongest correlation was with P(v-a)CO2
when compared with ScvO2 and hemoglobin in all data.
The P(v-a)CO2 and ScvO2 were significantly
higher and the hemoglobin and arterial oxygen saturation were
significantly lower in the high Ratio measurements (>1.68)
than low Ratio measurements (≤1.68). The P(v-a)CO2
was best for predicting a high Ratio. A P(v-a)CO2
threshold of 7 mmHg was associated with a sensitivity of 41.77%
and specificity of 90.62% for predicting a high Ratio. Conclusions A high P(v-a)CO2 is the most relevant contributor to a
high Ratio among all related factors in critically ill
patients.
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Affiliation(s)
- Huaiwu He
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Bo Tang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Can Ince
- Department of Intensive Care, Erasmus MC University Hospital Rotterdam, Rotterdam, Netherlands
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Ospina-Tascón GA, Madriñán HJ. Combination of O 2 and CO 2-derived variables to detect tissue hypoxia in the critically ill patient. J Thorac Dis 2019; 11:S1544-S1550. [PMID: 31388459 DOI: 10.21037/jtd.2019.03.52] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Oxygen-derived parameters have been traditionally used to guide resuscitation during shock states. Nevertheless, normalization of venous oxygen saturation does not exclude the persistence of tissue hypoperfusion and tissue hypoxia. Combination of O2 and CO2-derived variables has consistently demonstrated to be related with clinical outcomes and its variations could anticipate changes in lactate and also predict fluid responsiveness in terms of oxygen consumption. Here we discuss the potential mechanisms leading to increase the venous-to-arterial CO2 (Cv-aCO2) to arterial-to-venous O2 content difference (Ca-vO2), i.e., the Cv-aCO2/Ca-vO2 ratio, its potential clinical application, limitations and uncertainties. Finally, although biologically plausible, the potential applications of the Cv-aCO2/Ca-vO2 ratio in the clinical practice require to be confirmed.
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Affiliation(s)
- Gustavo A Ospina-Tascón
- Department of Intensive Care, Fundación Valle del Lili University Hospital-Universidad Icesi, Cali, Colombia
| | - Humberto J Madriñán
- Department of Intensive Care, Fundación Valle del Lili University Hospital-Universidad Icesi, Cali, Colombia
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43
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He HW, Long Y, Liu DW, Ince C. Resuscitation incoherence and dynamic circulation-perfusion coupling in circulatory shock. Chin Med J (Engl) 2019; 132:1218-1227. [PMID: 30896570 PMCID: PMC6511427 DOI: 10.1097/cm9.0000000000000221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Poor tissue perfusion/cellular hypoxia may persist despite restoration of the macrocirculation (Macro). This article reviewed the literatures of coherence between hemodynamics and tissue perfusion in circulatory shock. DATA SOURCES We retrieved information from the PubMed database up to January 2018 using various search terms or/and their combinations, including resuscitation, circulatory shock, septic shock, tissue perfusion, hemodynamic coherence, and microcirculation (Micro). STUDY SELECTION The data from peer-reviewed journals printed in English on the relationships of tissue perfusion, shock, and resuscitation were included. RESULTS A binary (coherence/incoherence, coupled/uncoupled, or associated/disassociated) mode is used to describe resuscitation coherence. The phenomenon of resuscitation incoherence (RI) has gained great attention. However, the RI concept requires a more practical, systematic, and comprehensive framework for use in clinical practice. Moreover, we introduce a conceptual framework of RI to evaluate the interrelationship of the Macro, Micro, and cell. The RI is divided into four types (Type 1: Macro-Micro incoherence + impaired cell; Type 2: Macro-Micro incoherence + normal cell; Type 3: Micro-Cell incoherence + normal Micro; and Type 4: both Macro-Micro and Micro-cell incoherence). Furthermore, we propose the concept of dynamic circulation-perfusion coupling to evaluate the relationship of circulation and tissue perfusion during circulatory shock. CONCLUSIONS The concept of RI and dynamic circulation-perfusion coupling should be considered in the management of circulatory shock. Moreover, these concepts require further studies in clinical practice.
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Affiliation(s)
- Huai-Wu He
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing 100730, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing 100730, China
| | - Da-Wei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing 100730, China
| | - Can Ince
- Department of Intensive Care, Erasmus MC University Hospital Rotterdam, Rotterdam 3015 CE, the Netherlands
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Kislitsina ON, Rich JD, Wilcox JE, Pham DT, Churyla A, Vorovich EB, Ghafourian K, Yancy CW. Shock - Classification and Pathophysiological Principles of Therapeutics. Curr Cardiol Rev 2019; 15:102-113. [PMID: 30543176 PMCID: PMC6520577 DOI: 10.2174/1573403x15666181212125024] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 10/11/2018] [Accepted: 12/10/2018] [Indexed: 01/10/2023] Open
Abstract
The management of patients with shock is extremely challenging because of the myriad of possible clinical presentations in cardiogenic shock, septic shock and hypovolemic shock and the limitations of contemporary therapeutic options. The treatment of shock includes the administration of endogenous catecholamines (epinephrine, norepinephrine, and dopamine) as well as various vasopressor agents that have shown efficacy in the treatment of the various types of shock. In addition to the endogenous catecholamines, dobutamine, isoproterenol, phenylephrine, and milrinone have served as the mainstays of shock therapy for several decades. Recently, experimental studies have suggested that newer agents such as vasopressin, selepressin, calcium-sensitizing agents like levosimendan, cardiac-specific myosin activators like omecamtiv mecarbil (OM), istaroxime, and natriuretic peptides like nesiritide can enhance shock therapy, especially when shock presents a more complex clinical picture than normal. However, their ability to improve clinical outcomes remains to be proven. It is the purpose of this review to describe the mechanism of action, dosage requirements, advantages and disadvantages, and specific indications and contraindications for the use of each of these catecholamines and vasopressors, as well as to elucidate the most important clinical trials that serve as the basis of contemporary shock therapy.
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Affiliation(s)
- Olga N Kislitsina
- Department of Cardiac Surgery Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States.,Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Jonathan D Rich
- Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Jane E Wilcox
- Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Duc T Pham
- Department of Cardiac Surgery Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Andrei Churyla
- Department of Cardiac Surgery Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Esther B Vorovich
- Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Kambiz Ghafourian
- Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Clyde W Yancy
- Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
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Gomez DE, Rodriguez-Lecompte JC, Lofstedt J, Arroyo LG, Nino-Fong R, McClure JT. Detection of endotoxin in plasma of hospitalized diarrheic calves. J Vet Emerg Crit Care (San Antonio) 2019; 29:166-172. [PMID: 30810269 DOI: 10.1111/vec.12815] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 12/06/2016] [Accepted: 01/14/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate whether lipopolysaccharide (LPS) is present in plasma of calves with naturally occurring diarrhea. The second objective was to determine whether plasma [LPS] correlates with clinical, hematological, biochemical, and acid-base variables, and whether [LPS] differs between surviving and nonsurviving diarrheic calves. DESIGN Prospective observational study (January 2012-May 2014). SETTING Veterinary teaching hospital. ANIMALS Thirty-four calves <28 days old admitted for diagnosis and treatment of diarrhea and 30 healthy control calves. MEASUREMENTS AND MAIN RESULTS Admission demographics, physical examination, blood gas, biochemistry analysis, and outcome data were recorded. Plasma concentration of LPS was determined using a bovine LPS ELISA assay. Plasma [LPS] was detected in both healthy and diarrheic calves. Plasma [LPS] was significantly higher in diarrheic than healthy calves (median: 0.99 ng/mL; Interquartile range (IQR): 0.068, vs 0.88 ng/mL; 0.065 ng/mL, respectively; P < 0.001). Plasma [LPS] was higher in nonsurviving (1.04 ng/mL; 0.07 ng/mL) than in surviving calves (0.98 ng/mL; 0.022 ng/mL; P < 0.001). Plasma [LPS] was higher in beef (1.07 ng/mL; 0.182 ng/mL) than in dairy diarrheic calves (0.99 ng/mL; 0.022 ng/mL; P < 0.001). In diarrheic calves, plasma [LPS] correlated with [l-lactate] (r2 = 0.496; P = 0.002); hypoglycemia (r2 = -0.453; P = 0.007); increased unmeasured strong ions (r2 = 0.332; P = 0.050), [Mg2+ ] (r2 = 0.475; P = 0.004), and [phosphate] (r2 = 0.468; P = 0.005), and increased aspartate aminotransferase activity (r2 = 0.348; P = 0.003). CONCLUSIONS This study highlights a potential role of LPS in the pathogenesis of metabolic derangements such as hyperlactatemia, hypoglycemia, and increased concentration of unmeasured strong anions in diarrheic calves. Further investigation evaluating the effect of LPS on l-lactate and glucose metabolism in diarrheic calves is warranted.
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Affiliation(s)
- Diego E Gomez
- Department of Health Management Atlantic Veterinary College, University of Prince Edward Island, Charlottetown, PE, Canada
| | - Juan C Rodriguez-Lecompte
- Department of Pathology and Microbiology, Atlantic Veterinary College, University of Prince Edward Island, Charlottetown, PE, Canada
| | - Jeanne Lofstedt
- Department of Health Management Atlantic Veterinary College, University of Prince Edward Island, Charlottetown, PE, Canada
| | - Luis G Arroyo
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Rodolfo Nino-Fong
- Department of Biomedical Sciences, Ross University School of Veterinary Medicine, St. Kitts and Nevis
| | - J Trenton McClure
- Department of Health Management Atlantic Veterinary College, University of Prince Edward Island, Charlottetown, PE, Canada
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Kwon HC, Cha YS, An GJ, Lee Y, Kim H. Usefulness of serum lactate as a predictor of successful discontinuation of continuous atropine infusion in patients with severe acute organophosphate poisoning. Clin Exp Emerg Med 2018; 5:177-184. [PMID: 30269453 PMCID: PMC6166043 DOI: 10.15441/ceem.17.238] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 08/15/2018] [Indexed: 11/23/2022] Open
Abstract
Objective In severe organophosphate (OP) poisoning, administration of atropine via continuous intravenous infusion is typically considered. To date, there have been no studies on predicting successful atropine discontinuation through plasma cholinesterase (PChE) and serum lactate levels, which are monitored during critical care in severe acute OP poisoning. Therefore, we retrospectively evaluated the usefulness of serum lactate and PChE as predictors of successful discontinuation of atropine infusion. Methods This retrospective observational study was performed on consecutive adult patients treated for severe acute OP poisoning between March 2011 and December 2016. We sequentially evaluated serum lactate and PChE levels on emergency department arrival and before a discontinuation trial of atropine infusion. Discontinuation of atropine intravenous infusion was attempted in patients after clearance of respiratory secretions and cessation of bronchoconstriction. Discontinuation of atropine infusion attempts were divided into successful and failed trials. Results A total of 95 trials were conducted in 62 patients. Serum lactate levels before trials were significantly different between patients with successful and failed trials. The area under the curve for prediction of successful atropine discontinuation using serum lactate levels before trial discontinuation were 0.742 (95% confidence interval, 0.638 to 0.846). PChE level was not significantly different between two groups. Conclusion Serum lactate levels before the discontinuation trial of atropine infusion served to predict successful discontinuation in severe acute OP poisoning.
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Affiliation(s)
- Ho Chul Kwon
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yong Sung Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Gyo Jin An
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yoonsuk Lee
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyun Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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Hourmozdi JJ, Gill J, Miller JB, Markin A, Adams B, Soi V, Jaehne AK, Taylor AR, Langberg S, Rodriguez L, Fox C, Uduman J, Yessayan LT, Rivers EP. Change in Lactate Levels After Hemodialysis in Patients With End-Stage Renal Disease. Ann Emerg Med 2018; 71:737-742. [DOI: 10.1016/j.annemergmed.2017.09.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 08/28/2017] [Accepted: 09/14/2017] [Indexed: 11/15/2022]
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Abstract
Circulatory shock is defined as an imbalance between tissue oxygen supply and demand, and mostly results from a loss of blood volume, cardiac pump failure, and/or reduction of vasomotor tone. The clinical hallmarks of circulatory shock are arterial hypotension and lactate acidosis. Since the degree and duration of hypotension are major determinants of outcome, vasopressor administration represents a cornerstone therapy to treat these patients. Current guidelines recommend the use of catecholamines as the drug of first choice. However, apart from their hemodynamic effects, which depend on the different receptor profile, receptor affinity, receptor density, and the relative potency of the individual molecule, catecholamines have numerous other biological effects as a result of the ubiquitous presence of their receptors. In shock states, catecholamines aggravate hypermetabolism by promoting hyperglycemia and hyperlactatemia, and further increase oxygen demands, which can contribute to further organ damage. In the mitochondria, catecholamines may promote mitochondrial uncoupling, and aggravate oxidative stress, thereby contributing to the progression of mitochondrial dysfunction. Immunological side effects have also gained specific attention. Although both pro- and anti-inflammatory effects have been described, current evidence strongly indicates an immunosuppressive effect, thereby making patients potentially vulnerable to secondary infections. Catecholamines may not only decrease splanchnic perfusion due to their vasoconstrictor properties, but can also directly impair gastrointestinal motility. This article reviews the non-hemodynamic effects of different catecholamines, both under physiologic and pathophysiologic conditions, with a special focus on energy metabolism, mitochondrial function, immune response, and the gastrointestinal system.
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49
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The ten pitfalls of lactate clearance in sepsis. Intensive Care Med 2018; 45:82-85. [PMID: 29754310 PMCID: PMC6334727 DOI: 10.1007/s00134-018-5213-x] [Citation(s) in RCA: 143] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 05/05/2018] [Indexed: 12/22/2022]
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50
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Scheiner B, Funk GC. Reply to: "Acid-base disorders in liver disease". J Hepatol 2018; 68:618-619. [PMID: 29061515 DOI: 10.1016/j.jhep.2017.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 10/16/2017] [Indexed: 01/23/2023]
Affiliation(s)
- Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Georg-Christian Funk
- Department of Respiratory and Critical Care Medicine, Otto Wagner Spital, Vienna, Austria.
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