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

Phosphodiesterase 3 inhibitors do not influence lactate kinetics and clinical outcomes in patients with septic shock: A multicentre cohort study

PURPOSE

We investigated the association between the administration of phosphodiesterase 3 inhibitors (PDE3i) and lactate kinetics, resolution of organ failure, ICU and hospital length of stay (LOS) and hospital mortality in a retrospective cohort of patients with septic shock and persistently elevated lactate concentrations.

MATERIAL AND METHODS

Patients with septic shock and two arterial lactate concentrations ≥4 mmol/L with at least 4 h between measurements were eligible. Clinical data of the first four days of admission were collected in an online database. For each patient, the area between the actual lactate concentrations and 2.2 mmol/L (AUClact2.2), was calculated for three days.

RESULTS

Data on 229 patients from 10 hospitals were collected, of whom 123 received PDE3i (54%). First, a linear multivariate model was developed to predict AUClact2.2 (R2 = 0.57). Adding PDE3i as a cofactor did not affect R2. Second, 60 patients receiving PDE3i at any time between days 0 and 2 were compared to 60 propensity matched no-PDE3i patients. Third, 30 patients who received PDE3i from ICU admission to day 3 were compared to 30 propensity-matched no-PDE3i patients. These analyses showed no differences in AUClact2.2, SOFA scores, ICU or hospital LOS or hospital mortality between treatment groups.

CONCLUSIONS

No association was found between the administration of PDE3i and lactate kinetics, resolution of organ failure, ICU or hospital LOS or hospital mortality.

Clinical characteristics and prognosis of patients with early sepsis-related liver injury in Northeast China

Background: Sepsis-associated liver injury (SALI) occurs in about a third of septic patients, and it is often a poor prognostic factor. However, there are few studies on early SALI and its impact on the clinical course of sepsis. Here we explored the clinical characteristics, risk factors, and prognosis of early SALI. Methods: Two hundred and one patients with confirmed sepsis were divided into those with and without early SALI (on admission) based on liver function. The clinical characteristics and prognosis were compared between groups and associated factors identified by multivariable regression analysis. Results: Sepsis-related liver injury was present in 18.9% of septic patients on admission. High aspartate transaminase (AST), high direct bilirubin, and low plasma thromboplastin antecedent (PTA, factor XI) were risk factors for sepsis with SALI: the area under the AST curve was 0.825, corresponding to a sensitivity of 0.67 and a specificity of 0.93 (cutoff 91.6 U/L), the area under the direct bilirubin curve was 0.86, corresponding to a sensitivity of 0.83 and a specificity of 0.71 (cutoff 8.35 μmol/L), and the area under the PTA curve was 0.678, corresponding to a sensitivity of 0.47 and a specificity of 0.93 (cutoff 54.0). Conclusion: Septic patients with early SALI have early-onset coagulation disorders that must be recognized to instigate early intervention and halt sepsis progression. Elevated AST, PTA, and direct bilirubin may be independent risk markers of sepsis-related liver injury, and extra clinical vigilance is required when these factors are noted in patients with sepsis.

Effect of different shock conditions on mesenteric hemodynamics

BACKGROUND

Reduced effective circulating blood volume and impaired peripheral tissue perfusion play an important role in the pathophysiology of shock. However, there have been no studies examining the relationship between Doppler ultrasound of the superior mesenteric artery (SMA) under different shock conditions.

METHODS

We evaluated a total of 85 patients, including 63 patients with different types of shock and 22 in the control group. we included patients who were diagnosed with shock upon admission or developed shock during their hospital stay. At the same time, patients with stable hemodynamics, no use of vasoactive drugs and normal lactate levels were used as a control group. We collected SMA Doppler ultrasound parameters, including Peak Systolic Velocity (PSV), End Diastolic Velocity (EDV), Resistance Index (RI), pulsatility index (PI), Time-Averaged Mean Velocity (TAMV), and Blood Flow (BF).

RESULTS

In the cardiac shock group, SMA PSV, TAMV, and BF were lower compared to the other groups. There was no significant difference in SMA RI and PI between the different types of shock groups, but both were significantly lower than the control group. Cardiac index (CI) is correlated with SMA PSV (r = 0.487, P = 0.000) and TAMV (r = 0.538, P = 0.000), whereas SVRI is not correlated with SMA RI and PI. Lactate levels was correlation with SMA RI (r = -0.307, P = 0.000) and PI (r = -0.287, P = 0.000). The area under the ROC curve of SMA RI and PI to predict hyperlactatemia was 0.85[0.78-0.91] and 0.83[0.76-0.90].

CONCLUSIONS

The velocity parameters of SMA Doppler ultrasound such as TAMV and PSV can reflect cardiac function. The measurements of SMA RI and PI are correlated with lactate levels, having a positive predictive value for hyperlactatemia and provide guidance for fluid resuscitation in patients with shock in the future.

Clinical characteristics of extracorporeal cardiopulmonary resuscitation in China: a multicenter retrospective study

PURPOSE

Extracorporeal cardiopulmonary resuscitation (ECPR) might markedly increase the survival of selected patients with refractory cardiac arrest. But the application situation and indications remained unclear.

MATERIALS AND METHODS

We respectively reviwed all adult patients who underwent ECPR from January 2017 to March 2021. Patient characteristics, initiation and management of ECMO, complications, and outcomes were collected and compared between the survivors and nonsurvivors. LASSO regression was used to screen risk factors. Multivariate logistic regression was performed with several parameters screened by LASSO regression.

RESULTS

Data were reported from 42 ECMO centers covering 19 provinces of China. A total of 648 patients were included in the study, including 491 (75.8%) males. There were 11 ECPR centers in 2017, and the number increased to 42 in 2020. The number of patients received ECPR increased from 33 in 2017 to 274 in 2020, and the survival rate increased from 24.2% to 33.6%. Neurological complications, renal replacement therapy, epinephrine dosage after ECMO, recovery of spontaneous circulation before ECMO, lactate clearance and shockable rhythm were risk factors independently associated with outcomes of whole process. Sex, recovery of spontaneous circulation before ECMO, lactate, shockable rhythm and causes of arrest were pre-ECMO risk factors independently affecting outcomes.

CONCLUSIONS

From January 2017 to March 2021, the numbers of ECPR centers and cases in mainland China increased gradually over time, as well as the survival rate. Pre-ECMO risk factors, especially recovery of spontaneous circulation before ECMO, shockable rhythm and lactate, are as important as post-ECMO management,. Neurological complications are vital risk factors after ECMO that deserved close attention.

TRIAL REGISTRATION

NCT04158479, registered on 2019/11/08. https://clinicaltrials.gov/NCT04158479.

Enhancing SAPS-3 Predictive Accuracy with Initial, Peak, and Last Lactate Measurements in Septic Shock

Background/Objectives: Septic shock is a severe condition with high mortality necessitating precise prognostic tools for improved patient outcomes. This study aimed to evaluate the collective predictive value of the Simplified Acute Physiology Score 3 (SAPS-3) and lactate measurements (initial, peak, last, and clearance rates within the first 24 h) in patients with septic shock. Specifically, it sought to determine how these markers enhance predictive accuracy for 28-day mortality beyond SAPS-3 alone. Methods: This retrospective cohort study analyzed data from 66 septic shock patients at two ICUs of Vienna General Hospital (2017-2019). SAPS-3 and lactate levels (initial, peak, last measurement within 24 h, and 24 h clearance) were obtained from electronic health records. Logistic regression models were constructed to identify predictors of 28-day mortality, and receiver operating characteristic (ROC) curves assessed predictive accuracy. Results: Among 66 patients, 36 (55%) died within 28 days. SAPS-3 scores significantly differed between survivors and non-survivors (76 vs. 85 points; p = 0.016). First, last, and peak lactate were significantly higher in non-survivors compared to survivors (all p < 0.001). The combination of SAPS-3 and first lactate produced the highest predictive accuracy (AUC = 80.6%). However, 24 h lactate clearance was not predictive of mortality. Conclusions: Integrating SAPS-3 with lactate measurements, particularly first lactate, improves predictive accuracy for 28-day mortality in septic shock patients. First lactate serves as an early, robust prognostic marker, providing crucial information for clinical decision-making and care prioritization. Further large-scale studies are needed to refine these predictive tools and validate their efficacy in guiding treatment strategies.

Mortality Prediction by Kinetic Parameters of Lactate and S-Adenosylhomocysteine in a Cohort of Critically Ill Patients

Tissue hypoxia is associated with the development of organ dysfunction and death in critically ill patients commonly captured using blood lactate. The kinetic parameters of serial lactate evaluations are superior at predicting mortality compared with single values. S-adenosylhomocysteine (SAH), which is also associated with hypoxia, was recently established as a useful predictor of septic organ dysfunction and death. We evaluated the performance of kinetic SAH parameters for mortality prediction compared with lactate parameters in a cohort of critically ill patients. For lactate and SAH, maxima and means as well as the normalized area scores were calculated for two periods: the first 24 h and the total study period of up to five days following ICU admission. Their performance in predicting in-hospital mortality were compared in 99 patients. All evaluated parameters of lactate and SAH were significantly higher in non-survivors compared with survivors. In univariate analysis, the predictive power for mortality of SAH was higher compared with lactate in all forms of application. Multivariable models containing SAH parameters demonstrated higher predictive values for mortality than models based on lactate parameters. The optimal models for mortality prediction incorporated both lactate and SAH parameters. Compared with lactate, SAH displayed stronger predictive power for mortality in static and dynamic application in critically ill patients.

Hemodynamic Support in Sepsis

This review discusses recent evidence in managing sepsis-induced hemodynamic alterations and how it can be integrated with previous knowledge for actionable interventions in adult patients.

Prognostic value of serum lactate level for mortality in patients with acute kidney injury

BACKGROUND

Serum lactate is associated with mortality in diverse kinds of patients. This study aimed to investigate whether serum lactate level may independently predict mortality in acute kidney injury (AKI) patients.

METHODS

A total of 4461 AKI patients were collected from the Medical Information Mart for Intensive Care (MIMIC III) database and followed up for 365 days. According to serum lactate tertiles, participants were divided into three groups (Q1-Q3) by: Q1 ≤ 1.60 mg/dl, Q2 = 1.61-2.70 mg/dl, and Q3 ≥ 2.71 mg/dl. We calculated the hazard ratio (HR) and 95% confidence intervals (Cls) for mortality across each tertile of lactate by using the Q1 as reference and constructed four models to adjust for the HR of mortality.

RESULTS

Nonsurvivors had significantly higher lactate compared with patients in the survival group. Mortality rate gradually elevated with the increase in serum lactate level (Q1: 29.30%, Q2: 33.40%, Q3: 37.40%). When compared with Q1 after adjustment of all confounders, the HRs of Q3 still was 1.20 (95% Cl 1.05-1.37).

CONCLUSIONS

This study demonstrated that high serum lactate levels were an independent predictor of mortality in AKI patients.

Clinical usefulness of NT-proBNP as a prognostic factor for septic shock patients presenting to the emergency department

Plasma N-terminal prohormone of brain natriuretic peptide (NT-proBNP) level is primarily used as a biomarker for left ventricular (LV) dysfunction. It is influenced by various conditions, such as myocardial strain and situations affecting the clearance of NT-proBNP, including sepsis and shock. In this study, we investigated the appropriateness of NT-proBNP as a prognostic factor for septic shock. Patients with septic shock who visited the emergency department of the Ewha Womans' University Mokdong Hospital between January 1, 2018, and December 31, 2020, were classified into the survival group (those who survived in the hospital and were discharged) and the death group (those who died in the hospital). The effectiveness of NT-proBNP, lactate, and blood urea nitrogen as predictive factors of in-hospital mortality was evaluated using the area under the receiver operating characteristic (AUROC) curve. The AUROC curve was 0.678 and 0.648 for lactate and NT-proBNP, respectively, with lactate showing the highest value. However, there was no significant difference between lactate and NT-proBNP levels in the comparison of their AUROC curve (p = 0.6278). NT-proBNP could be a useful predictor of in-hospital mortality in patients with septic shock who present to the emergency department.

Effects of restrictive fluid therapy on the time to resolution of hyperlactatemia in ICU patients with septic shock. A secondary post hoc analysis of the CLASSIC randomized trial

PURPOSE

The aim of this study was to examine the effects of intravenous (IV) fluid restriction on time to resolution of hyperlactatemia in septic shock. Hyperlactatemia in sepsis is associated with worse outcome. Sepsis guidelines suggest targeting lactate clearance to guide fluid therapy despite the complexity of hyperlactatemia and the potential harm of fluid overload.

METHODS

We conducted a post hoc analysis of serial plasma lactate concentrations in a sub-cohort of 777 patients from the international multicenter clinical CLASSIC trial (restriction of intravenous fluids in intensive care unit (ICU) patients with septic shock). Adult ICU patients with septic shock had been randomized to restrictive (n = 385) or standard (n = 392) intravenous fluid therapy. The primary outcome, time to resolution of hyperlactatemia, was analyzed with a competing-risks regression model. Death and discharge were competing outcomes, and administrative censoring was imposed 72 h after randomization if hyperlactatemia persisted. The regression analysis was adjusted for the same stratification variables and covariates as in the original CLASSIC trial analysis.

RESULTS

The hazard ratios (HRs) for the cumulative probability of resolution of hyperlactatemia, in the restrictive vs the standard group, in the unadjusted analysis, with time split, were 0.94 (confidence interval (CI) 0.78-1.14) at day 1 and 1.21 (0.89-1.65) at day 2-3. The adjusted analyses were consistent with the unadjusted results.

CONCLUSION

In this post hoc retrospective analysis of a multicenter randomized controlled trial (RCT), a restrictive intravenous fluid strategy did not seem to affect the time to resolution of hyperlactatemia in adult ICU patients with septic shock.

Renin as a Prognostic Marker in Intensive Care and Perioperative Settings: A Scoping Review

Serum renin increases in response to sympathetic nerve activation and hypotension. Recent studies have reported the association of serum renin levels with adverse clinical outcomes in acute care settings. This scoping review aimed to systematically review the available literature on renin as a prognostic marker in intensive care and perioperative patients. We searched for studies published since inception until March 31, 2023, which assessed the association between serum renin levels and clinical outcomes or the effect of synthetic angiotensin II administration on serum renin levels in critically ill and perioperative patients in PubMed, Embase, and the Cochrane Library. The primary outcome was mortality at the longest follow-up; the secondary outcomes were adverse renal outcomes (ie, acute kidney injury, the need for renal replacement therapy, and major adverse kidney events), hemodynamic instability, outcomes to angiotensin II administration, and prognostic performance for mortality when compared with lactate. Among the 2081 studies identified, we included 16 studies with 1573 patients (7 studies on shock, 5 on nonspecific critical illness, 2 on cardiac surgery, 1 on noncardiac surgery, and 1 on coronavirus disease 2019). A significant association between serum renin levels and poor outcomes was identified in 14 studies, with 10 studies demonstrating an association with mortality. One post hoc analysis found that angiotensin II administration reduced mortality in patients with markedly elevated renin values. Two studies showed that renin was superior to lactate as a prognostic marker of mortality. Our scoping review showed that elevated serum renin levels may be associated with clinically relevant outcomes among various perioperative and intensive care populations. Increased serum renin levels may identify patients in which synthetic angiotensin II administration improves clinical outcomes and may outperform serum lactate in predicting mortality.

Association between early lactate-related variables and 6-month neurological outcome in out-of-hospital cardiac arrest patients

INTRODUCTION

The role of lactate measurement in out-of-hospital cardiac arrest (OHCA) survivors remains controversial. We assessed the association between early lactate-related variables, OHCA characteristics, and long-term neurological outcome.

METHODS

In OHCA patients who received targeted temperature management, lactate levels were measured at 0, 12, and 24 h after the return of spontaneous circulation. We calculated lactate clearance and time-weighted cumulative lactate (TWCL), which represent the area under the time-lactate curve. The area under the receiver operating characteristic curve (AUC) and the adjusted odds ratios (AORs) of lactate-related variables for predicting 6-month poor outcome (Cerebral Performance Category 3-5) were evaluated. Interactions between lactate variables and characteristics of OHCA were evaluated by a multivariable logistic model with interaction terms and subgroup analysis.

RESULTS

A total of 347 OHCA patients were included. After adjustment, higher lactate levels at the three time points were associated with a poor outcome (AOR 1.10 [95% CI, 1.03-1.18], AOR 1.15 [95% CI, 1.02-1.29], and AOR 1.36 [95% CI, 1.15-1.60], respectively), while TWCL was the only lactate kinetics variable associated with a poor outcome (AOR 1.29 [95% CI, 1.12-1.49]). We identified several interactions between lactate-related variables and OHCA characteristics. In particular, the AUC of TWCL was excellent in cases of noncardiac etiology (AUC 0.92 [95% CI, 0.86-0.96] but only moderate in cardiac etiology (AUC 0.69 [95% CI, 0.62-0.75]).

CONCLUSIONS

Early lactate levels, especially at 24 h, and TWCL were independent predictors of neurologic outcome in these patients, whereas lactate clearance was not. The prognostic ability of lactate-related variables varied depending on the OHCA characteristics.

The Relationship Between Lactate and Lactate Clearance with In-Hospital Mortality in Unselected Emergency Department Patients

INTRODUCTION

Lactate is a frequently used biomarker in emergency departments (EDs), especially in critically ill patients. The aim of this study is to investigate the relationship between lactate and lactate clearance with in-hospital mortality in unselected ED patients.

METHODS

This study was carried out retrospectively in the ED of a tertiary hospital. Patients aged 18 years and older whose blood lactate level was obtained in the ED were included in the study. Patients whose lactate value did not have sufficient analytical accuracy, whose lactate value was recorded in the system 180 minutes after admission, who were admitted to the ED as cardiac arrest, and whose ED or hospital outcome was unknown were excluded from the study. According to the first measured lactate value, the patients were divided into three groups: < 2.0mmol/L, 2.0-3.9mmol/L, and ≥ 4.0mmol/L. Lactate clearance was calculated and recorded in patients with one-to-four hours between two lactate values.

RESULTS

During the five-year study period, a total of 1,070,406 patients were admitted to the ED, of which 114,438 (10.7%) received blood gas analysis. The median age of 81,449 patients included in the study was 58 years (IQR: 30, min: 18-max: 117) and 54.4% were female. The study found that non-trauma patients with a lactate level between 2.0-3.9mmol/L had a 2.5-times higher mortality risk, while those with a lactate level of ≥ 4.0mmol/L had a 20.8-times higher risk, compared to those with a lactate level < 2.0mmol/L. For trauma patients, the mortality risk was three-times higher for those with lactate levels between 2.0-3.9mmol/L and nine-times higher for those with a lactate level of ≥ 4.0mmol/L, compared to those with a lactate level < 2.0mmol/L. Among patients with a first measured lactate value ≥ 4.0mmol/L and a two-hour lactate clearance < 20%, the mortality rate was 19.7%. In addition, lactate, lactate clearance, and age were independent variables for mortality in this patient group.

CONCLUSION

The lactate value in unselected patients in the ED is a biomarker that can be used to predict the prognosis of the patients. In addition, lactate, lactate clearance, and age are independent predictors of mortality.

Serum lactate normalization time associated with prolonged postoperative ileus after surgical management of the small bowel and/or mesenteric injuries

BACK GROUND

Determining the optimal timing of postoperative oral feeding in trauma patients who have undergone abdominal surgery with small bowel and/or mesenteric injuries is challenging. The aim of this study is to investigate serum lactate as a factor that can predict oral feeding tolerance and prolonged postoperative ileus (PPOI) in patients who underwent surgery for small bowel and/or mesenteric injury due to trauma.

METHODS

The single center retrospective observational study was conducted on 367 patients who underwent surgery for small bowel and/or mesenteric injury between January 2013 and July 2021. The patient group was divided into two groups based on whether the peak serum lactate was over 2mmol/L (18 mg/dL). In the group of lactate > 2mmol/L, it was divided into prolonged postoperative ileus (PPOI) groups and groups rather than PPOI.

RESULTS

Patients in the peak serum lactate > 2 group had tendency to use vasopressors, lower initial systolic blood pressure, larger number of packed red blood cells for 24 h, higher injury severity score, higher PPOI incidence, and a tendency for delayed oral intake tolerance. In peak serum lactate greater than 2 mmol/L group, the lactate normalization time (OR 1.699, p = 0.04), quantity of FFP transfusion for 24 h (OR 1.145, p = 0.012), and creatine kinase (OR 1.001, p = 0.023) were related to PPOI. The lactate normalization time had the highest correlation.

CONCLUSION

In patients undergoing surgical management for small bowel and/or mesenteric injury after trauma, serum lactate normalization time affects oral intake tolerance and prolongs postoperative ileus.

Association between normalized lactate load and in-hospital mortality in patients with acute myocardial infarction

BACKGROUND

Lactate was a prognostic indicator for acute myocardial infarction (AMI) patients. However, the association between normalized lactate load, representing hypoxic burden over time, and in-hospital mortality remained uncertain.

METHODS

The data for this study was obtained from the Medical Information Mart for Intensive Care IV (MIMIC-IV, version 2.1) database. The normalized lactate load, describing the average intensity of hyperlactatemia, was calculated as the area under the curve (AUC) of lactate divided by time. 5882 AMI patients enrolled in this study were divided into survivor (n = 5015), and non-survivor group (n = 867). The primary endpoint was in-hospital mortality. Receiver operating characteristic (ROC) curves were generated to assess the predictive efficacy of normalized lactate load for in-hospital mortality, and areas under the curves of different parameters were compared using DeLong test. Multivariate binary logistic regression analysis was employed to explore the association between normalized lactate load and in-hospital mortality. The adjusting variables included age, gender, ethnicity, heart rate, systolic blood pressure, congestive heart failure, shock, dyslipidemia, cardiac arrest, cerebrovascular disease, neutrophil, lymphocyte, creatinine, blood nitrogen urea, clopidogrel, beta-blockers, angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB), statins, dialysis, extracorporeal membrane oxygenation (ECMO), the Sequential Organ Failure Assessment (SOFA) score and Simplified Acute Physiology Score II (SAPS II). Restricted cubic spline (RCS) was conducted to evaluate nonlinear associations of normalized lactate load with in-hospital mortality.

RESULTS

The overall in-hospital mortality rate was 14.7%. After adjusting for confounding variables, normalized lactate load was independently associated with increased risk of in-hospital mortality (Normalized lactate load≥2.6 vs Normalized lactate load<2.6: OR, 95% CI: 1.56, 1.27-1.93). The RCS demonstrated a positive linear relationship between normalized lactate load and in-hospital mortality (non-linear p = 0.725). ROC curves showed that normalized lactate load was better than first lactate, maximum lactate, and mean lactate in predicting in-hospital mortality, but lower than SOFA and SAPS II. Among participants with at least nine lactate measures, normalized lactate load showed predictive performance comparable to SOFA and SAPS II.

CONCLUSION

Normalized lactate load can be used to predict the prognosis of in-hospital mortality in AMI patients, and its prediction performance increases with the increase of lactate measurement.

Improving perioperative care in low-resource settings with goal-directed therapy: a narrative review

Perioperative Goal-Directed Therapy (PGDT) has significantly showed to decrease complications and risk of death in high-risk patients according to numerous meta-analyses. The main goal of PGDT is to individualize the therapy with fluids, inotropes, and vasopressors, during and after surgery, according to patients' needs in order to prevent organic dysfunction development. In this opinion paper we aimed to focus a discussion on possible alternatives to invasive hemodynamic monitoring in low resource settings.

The Predictive Role of Lactate in the Emergency Department in Patients with Severe Dyspnea

Objective

An accurate identification of patients at the need for prioritized diagnostics and care are crucial in the emergency department (ED). Blood gas (BG) analysis is a widely available laboratory test, which allows to measure vital parameters, including markers of ventilation and perfusion. The aim of our analysis was to assess whether blood gas parameters in patients with dyspnea at an increased risk of respiratory failure admitted to the ED can predict short-term outcomes.

Methods

The study group eventually consisted of 108 patients, with available BG analysis. The clinical and laboratory parameters were retrospectively evaluated, and three groups were distinguished-arterial blood gas (ABG), venous blood gas (VBG), and mixed blood gas. The primary endpoint was short-term, all-cause mortality during the follow-up of median (quartile 1-quartile 3) 2 (1-4) months. The independent risk factors for mortality that could be obtained from blood gas sampling were evaluated.

Results

The short-term mortality was 35.2% (38/108). Patients who died were more frequently initially assigned to the red triage risk group, more burdened with comorbidities, and the median SpO2 on admission was significantly lower than in patients who survived the follow-up period. In the multivariable analysis, lactate was the strongest independent predictor of death, with 1 mmol/L increasing all-cause mortality by 58% in ABG (95% CI: 1.01-2.47), by 80% in VBG (95% CI: 1.13-2.88), and by 68% in the mixed blood gas analysis (95% CI: 1.22-2.31), what remained significant in VBG and mixed group after correction for base excess. In each group, pH, pO2, and pCO2 did not predict short-term mortality.

Conclusions

In patients admitted to the ED due to dyspnea, at risk of respiratory failure, lactate levels in arterial, venous, and mixed blood samples are independent predictors of short-term mortality.

Prolyl hydroxylase domain inhibitor is an effective pre-hospital pharmaceutical intervention for trauma and hemorrhagic shock

Pre-hospital potentially preventable trauma related deaths are mainly due to hypoperfusion-induced tissue hypoxia leading to irreversible organ dysfunction at or near the point of injury or during transportation prior to receiving definitive therapy. The prolyl hydroxylase domain (PHD) is an oxygen sensor that regulates tissue adaptation to hypoxia by stabilizing hypoxia inducible factor (HIF). The benefit of PHD inhibitors (PHDi) in the treatment of anemia and lactatemia arises from HIF stabilization, which stimulates endogenous production of erythropoietin and activates lactate recycling through gluconeogenesis. The results of this study provide insight into the therapeutic roles of MK-8617, a pan-inhibitor of PHD-1, 2, and 3, in the mitigation of lactatemia in anesthetized rats with polytrauma and hemorrhagic shock. Additionally, in an anesthetized rat model of lethal decompensated hemorrhagic shock, acute administration of MK-8617 significantly improves one-hour survival and maintains survival at least until 4 h following limited resuscitation with whole blood (20% EBV) at one hour after hemorrhage. This study suggests that pharmaceutical interventions to inhibit prolyl hydroxylase activity can be used as a potential pre-hospital countermeasure for trauma and hemorrhage at or near the point of injury.

Towards the personalization of septic shock resuscitation: the fundamentals of ANDROMEDA-SHOCK-2 trial

Septic shock is a highly lethal and prevalent disease. Progressive circulatory dysfunction leads to tissue hypoperfusion and hypoxia, eventually evolving to multiorgan dysfunction and death. Prompt resuscitation may revert these pathogenic mechanisms, restoring oxygen delivery and organ function. High heterogeneity exists among the determinants of circulatory dysfunction in septic shock, and current algorithms provide a stepwise and standardized approach to conduct resuscitation. This review provides the pathophysiological and clinical rationale behind ANDROMEDA-SHOCK-2, an ongoing multicenter randomized controlled trial that aims to compare a personalized resuscitation strategy based on clinical phenotyping and peripheral perfusion assessment, versus standard of care, in early septic shock resuscitation.

The Effectiveness of Prehospital Subcutaneous Continuous Lactate Monitoring in Adult Trauma: A Systematic Review

INTRODUCTION

Existing diagnostics for polytrauma patients continue to rely on non-invasive monitoring techniques with limited sensitivity and specificity for critically unwell patients. Lactate is a known diagnostic and prognostic marker used in infection and trauma and has been associated with mortality, need for surgery, and organ dysfunction. Point-of-care (POC) testing allows for the periodic assessment of lactate levels; however, there is an associated expense and equipment burden associated with repeated sampling, with limited feasibility in prehospital care. Subcutaneous lactate monitoring has the potential to provide a dynamic assessment of physiological lactate levels and utilize these trends to guide management and response to given treatments.

STUDY OBJECTIVE

The aim of this study was to appraise the current literature on dynamic subcutaneous continuous lactate monitoring (SCLM) in adult trauma patients and its use in lactate-guided therapy in the prehospital environment.

METHODS

The systematic review was conducted in accordance with the PRISMA guidelines and registered with PROSPERO. Searched databases included PubMed, EMBASE via Ovid SP, Cochrane Library, and Web of Science. Databases were searched from inception to March 29, 2022. Relevant manuscripts were further scrutinized for reference citations to interrogate the fullness of the adjacent literature.

RESULTS

Searches returned 600 studies, including 551 unique manuscripts. Following title and abstract screening, 14 manuscripts met the threshold for full-text sourcing. Subsequent to the scrutiny of all 14 manuscripts, none fully met the specified eligibility criteria. Following careful examination, no article was found to cover the exact area of scientific inquiry due to disparity in technological or environmental characteristics.

CONCLUSION

Little is known about the utility of dynamic subcutaneous lactate monitoring, and this review highlights a clear gap in current literature. Novel subcutaneous lactate monitors are in development, and the literature describing the prototype experimentation has been summarized. These studies demonstrate device accuracy, which shows a close correlation with venous lactate while providing dynamic readings without significant lag times. Their availability and cost remain barriers to implementation at present. This represents a clear target for future feasibility studies to be conducted into the clinical use of dynamic subcutaneous lactate monitoring in trauma and resuscitation.

Anaerobic threshold using sweat lactate sensor under hypoxia

We aimed to investigate the reliability and validity of sweat lactate threshold (sLT) measurement based on the real-time monitoring of the transition in sweat lactate levels (sLA) under hypoxic exercise. In this cross-sectional study, 20 healthy participants who underwent exercise tests using respiratory gas analysis under hypoxia (fraction of inspired oxygen [FiO2], 15.4 ± 0.8%) in addition to normoxia (FiO2, 20.9%) were included; we simultaneously monitored sLA transition using a wearable lactate sensor. The initial significant elevation in sLA over the baseline was defined as sLT. Under hypoxia, real-time dynamic changes in sLA were successfully visualized, including a rapid, continual rise until volitionary exhaustion and a progressive reduction in the recovery phase. High intra- and inter-evaluator reliability was demonstrated for sLT's repeat determinations (0.782 [0.607-0.898] and 0.933 [0.841-0.973]) as intraclass correlation coefficients [95% confidence interval]. sLT correlated with ventilatory threshold (VT) (r = 0.70, p < 0.01). A strong agreement was found in the Bland-Altman plot (mean difference/mean average time: - 15.5/550.8 s) under hypoxia. Our wearable device enabled continuous and real-time lactate assessment in sweat under hypoxic conditions in healthy participants with high reliability and validity, providing additional information to detect anaerobic thresholds in hypoxic conditions.

Association between intraoperative hyperglycemia/hyperlactatemia and acute kidney injury following on-pump cardiac surgery: a retrospective cohort study

Background

Despite the long-lasting notion about the substantial contribution of intraoperative un-stabilization of homeostasis factors on the incidence on acute kidney injury (AKI), the possible influence of intraoperative glucose or lactate management, as a modifiable factor, on the development of AKI remains inconclusive.

Objectives

To investigated the relationship between intraoperative hyperglycemia, hyperlactatemia, and postoperative AKI in cardiac surgery.

Methods

A retrospective cohort study was conducted among 4,435 adult patients who underwent on-pump cardiac surgery from July 2019 to March 2022. Intraoperative hyperglycemia and hyperlactatemia were defined as blood glucose levels >10 mmol/L and lactate levels >2 mmol/L, respectively. The primary outcome was the incidence of AKI. All statistical analyses, including t tests, Wilcoxon rank sum tests, chi-square tests, Fisher's exact test, Kolmogorov-Smirnov test, logistic regression models, subgroup analyses, collinearity analysis, and receiver operating characteristic analysis, were performed using the statistical software program R version 4.1.1.

Results

Among the 4,435 patients in the final analysis, a total of 734 (16.55%) patients developed AKI after on-pump cardiac surgery. All studied intraoperative metabolic disorders was associated with increased AKI risk, with most pronounced odds ratio (OR) noted for both hyperglycemia and hyperlactatemia were present intraoperatively [adjusted OR 3.69, 95% confidence intervals (CI) 2.68-5.13, p < 0.001]. Even when hyperglycemia or hyperlactatemia was present alone, the risk of postoperative AKI remained elevated (adjusted OR 1.97, 95% CI 1.50-2.60, p < 0.001).

Conclusion

The presence of intraoperative hyperglycemia and hyperlactatemia may be associated with postoperative acute kidney injury (AKI) in patients undergoing on-pump cardiac surgery. Proper and timely interventions for these metabolic disorders are crucially important in mitigating the risk of AKI.

Machine Learning Algorithms Predict Successful Weaning From Mechanical Ventilation Before Intubation: Retrospective Analysis From the Medical Information Mart for Intensive Care IV Database

BACKGROUND

The prediction of successful weaning from mechanical ventilation (MV) in advance of intubation can facilitate discussions regarding end-of-life care before unnecessary intubation.

OBJECTIVE

We aimed to develop a machine learning-based model that predicts successful weaning from ventilator support based on routine clinical and laboratory data taken before or immediately after intubation.

METHODS

We used the Medical Information Mart for Intensive Care IV database, which is an open-access database covering 524,740 admissions of 382,278 patients in Beth Israel Deaconess Medical Center, United States, from 2008 to 2019. We selected adult patients who underwent MV in the intensive care unit (ICU). Clinical and laboratory variables that are considered relevant to the prognosis of the patient in the ICU were selected. Data collected before or within 24 hours of intubation were used to develop machine learning models that predict the probability of successful weaning within 14 days of ventilator support. Developed models were integrated into an ensemble model. Performance metrics were calculated by 5-fold cross-validation for each model, and a permutation feature importance and Shapley additive explanations analysis was conducted to better understand the impacts of individual variables on outcome prediction.

RESULTS

Of the 23,242 patients, 19,025 (81.9%) patients were successfully weaned from MV within 14 days. Using the preselected 46 clinical and laboratory variables, the area under the receiver operating characteristic curve of CatBoost classifier, random forest classifier, and regularized logistic regression classifier models were 0.860 (95% CI 0.852-0.868), 0.855 (95% CI 0.848-0.863), and 0.823 (95% CI 0.813-0.832), respectively. Using the ensemble voting classifier using the 3 models above, the final model revealed the area under the receiver operating characteristic curve of 0.861 (95% CI 0.853-0.869), which was significantly better than that of Simplified Acute Physiology Score II (0.749, 95% CI 0.742-0.756) and Sequential Organ Failure Assessment (0.588, 95% CI 0.566-0.609). The top features included lactate and anion gap. The model's performance achieved a plateau with approximately the top 21 variables.

CONCLUSIONS

We developed machine learning algorithms that can predict successful weaning from MV in advance to intubation in the ICU. Our models can aid the appropriate management for patients who hesitate to decide on ventilator support or meaningless end-of-life care.

State of the Management of Infections Caused by Multidrug-Resistant Gram-Negative Organisms

In the past decade, the prevalence of multidrug-resistant gram-negative (MDR-GN) bacterial infections has increased significantly, leading to higher rates of morbidity and mortality. Treating these infections poses numerous challenges, particularly when selecting appropriate empiric therapy for critically ill patients for whom the margin for error is low. Fortunately, the availability of new therapies has improved the treatment landscape, offering safer and more effective options. However, there remains a need to establish and implement optimal clinical and therapeutic approaches for managing these infections. Here, we review strategies for identifying patients at risk for MDR-GN infections, propose a framework for the choice of empiric and definitive treatment, and explore effective multidisciplinary approaches to managing patients in the hospital while ensuring a safe transition to outpatient settings.

Association between Serum Lactate and Morbidity and Mortality in Neonates: A Systematic Review and Meta-Analysis

OBJECTIVE

Lactate is a marker of hypoperfusion in critically ill patients. Whether lactate is useful for identifying and stratifying neonates with a higher risk of adverse outcomes remains unknown. This study aimed to investigate the association between lactate and morbidity and mortality in neonates.

METHODS

A meta-analysis was performed to determine the association between blood lactate levels and outcomes in neonates. Ovid MEDLINE, EMBASE, Cochrane Library, and ClinicalTrials.gov were searched from inception to 1 May 2021. A total of 49 observational studies and 14 data accuracy test studies were included. The risk of bias was assessed using the Newcastle-Ottawa Scale for observational studies and the QUADAS-2 tool for data accuracy test studies. The primary outcome was mortality, while the secondary outcomes included acute kidney injury, necessity for renal replacement therapy, neurological outcomes, respiratory morbidities, hemodynamic instability, and retinopathy of prematurity.

RESULTS

Of the 3184 articles screened, 63 studies fulfilled all eligibility criteria, comprising 46,069 neonates. Higher lactate levels are associated with mortality (standard mean difference, -1.09 [95% CI, -1.46 to -0.73]). Using the estimated sensitivity (0.769) and specificity (0.791) and assuming a prevalence of 15% for adverse outcomes (median of prevalence among studies) in a hypothetical cohort of 10,000 neonates, assessing the lactate level alone would miss 346 (3.46%) cases (false negative) and wrongly diagnose 1776 (17.76%) cases (false positive).

CONCLUSIONS

Higher lactate levels are associated with a greater risk of mortality and morbidities in neonates. However, our results do not support the use of lactate as a screening test to identify adverse outcomes in newborns. Research efforts should focus on analyzing serial lactate measurements, rather than a single measurement.

Quick Sequential Organ Failure Assessment Score, Lactate, and Neutrophil-Lymphocyte Ratio Help in Diagnosis and Mortality Prediction during Golden Hour of Sepsis in Emergency Department

Introduction

Sepsis is a life-threatening condition with a very narrow golden period in which confirmatory diagnosis may change the outcome dramatically. No confirmatory biomarker is available till date for early diagnosis of sepsis. This study aimed to evaluate the combined and independent role of quick sequential organ failure assessment (qSOFA) score, lactate, and neutrophil-lymphocyte ratio (NLR) in diagnosis and mortality prediction in early sepsis.

Methods

This was a hospital-based, single-center, prospective cohort study conducted in a tertiary care institute, Karnataka, India. Three hundred adult sepsis patients were recruited during 10-month period, and demographic data, qSOFA score, lactate, NLR, and culture samples were collected in ED within 1 h of admission. Outcome groups (survivor and nonsurvivor) were statistically analyzed with relative frequencies (%), median, mean ± standard deviation with 95% confidence interval (CI), univariate, bivariate, and multivariate logistic regression analysis, and Receiver -operating characteristic curve (ROC) curve to test the predictive ability of initial levels of three biomarkers.

Results

Sepsis was more prevalent among middle-aged male patients. Male gender (odds ratio [OR], 6.9; 95% CI: 1.61-30.1), qSOFA (OR, 154; 95% CI: 15-1565), and lactate (OR, 1.36; 95% CI: 22-833) show 97% (area under the curve) predictive accuracy of the model for sepsis on bivariate and multivariate logistic regression analysis. A significant rise in NLR was a poor outcome indicator on univariate analysis (P = 0.773).

Conclusion

All three biomarkers are good outcome predictors whereas qSOFA and lactate have diagnostic significance in early sepsis. These markers can be used for patient triaging, minimizing culture report dependence for treatment and ultimately the outcome.

Permissive Hypotension Has No Deleterious Impact on Fluid Balance or Kidney Function

OBJECTIVES

Mean arterial hypotension between 55 and 65 mm Hg could be tolerated safely in the absence of tissue hypoperfusion, but the consequences on fluid balance and kidney function remain unknown.

DESIGN

During a 1-year period, we retrospectively collected data of consecutive septic patients admitted for sepsis with a mean arterial pressure (MAP) less than 65 mm Hg despite fluid resuscitation.

SETTING

Medical 18-bed ICU in a tertiary teaching hospital.

PATIENTS

Septic patients with a MAP less than 65 mm Hg despite initial resuscitation.

INTERVENTIONS

In our ICU, MAP between 55 and 65 mm Hg was tolerated in the absence of peripheral hypoperfusion (permissive hypotension) or corrected using norepinephrine (septic shock group) when peripheral tissue hypoperfusion was present.

MEASUREMENTS AND MAIN RESULTS

Ninety-four consecutive septic patients were included, 15 in the permissive hypotension group and 79 in the septic shock group. Median age was 66 years (57-77 yr) and 42% were women. The main sources of infection were respiratory (45%) and abdominal (18%). Severity was more important in septic shock group with higher Sequential Organ Failure Assessment score (7 [5-10] vs. 4 [1-6]; p < 0.0001), more frequent organ support therapy and ultimately higher mortality (38 vs. 0%; p < 0.01). The total volume of crystalloids infused before ICU admission was not different between groups (1930 ± 250 vs. 1850 ± 150 mL; p = 0.40). Within the 6 first hours of ICU stay, patients in the permissive hypotension group received less fluids (530 ± 170 vs. 1100 ± 110 mL; p = 0.03) and had higher urinary output (1.4 mL [0.88-2.34 mL] vs. 0.47 mL/kg/hr [0.08-1.25 mL/kg/hr]; p < 0.001). In addition, kidney injury evaluated using KDIGO score was lower in the permissive hypotension group at 48 hours (0 hr [0-1 hr] vs. 1 hr [0-2 hr]; p < 0.05).

CONCLUSIONS

In septic patients without clinical peripheral hypoperfusion, mean arterial hypotension between 55 and 65 mm Hg could be tolerated safely without vasopressor infusion and was not associated with excessive fluid administration or kidney damage.

Erector spinae muscle-based nomogram for predicting in-hospital mortality among older patients with severe community-acquired pneumonia

BACKGROUND

No multivariable model incorporating erector spinae muscle (ESM) has been developed to predict clinical outcomes in older patients with severe community-acquired pneumonia (SCAP). This study aimed to construct a nomogram based on ESM to predict in-hospital mortality in patients with SCAP.

METHODS

Patients aged ≥ 65 years with SCAP were enrolled in this prospective observational study. Least absolute selection and shrinkage operator and multivariable logistic regression analyses were used to identify risk factors for in-hospital mortality. A nomogram prediction model was constructed. The predictive performance was evaluated using the concordance index (C-index), calibration curve, net reclassification improvement (NRI), integrated discrimination improvement (IDI), and decision curve analysis.

RESULTS

A total of 490 patients were included, and the in-hospital mortality rate was 36.1%. The nomogram included the following independent risk factors: mean arterial pressure, peripheral capillary oxygen saturation, Glasgow Coma Scale score (GCS), lactate, lactate dehydrogenase, blood urea nitrogen levels, and ESM cross-sectional area. Incorporating ESM into the base model with other risk factors significantly improved the C-index from 0.803 (95% confidence interval [CI], 0.761-0.845) to 0.836 (95% CI, 0.798-0.873), and these improvements were confirmed by category-free NRI and IDI. The ESM-based nomogram demonstrated a high level of discrimination, good calibration, and overall net benefits for predicting in-hospital mortality compared with the combination of confusion, urea, respiratory rate, blood pressure, and age ≥ 65 years (CURB-65), Pneumonia Severity Index (PSI), Acute Physiology and Chronic Health Evaluation II (APACHEII), and Sequential Organ Failure Assessment (SOFA).

CONCLUSIONS

The proposed ESM-based nomogram for predicting in-hospital mortality among older patients with SCAP may help physicians to promptly identify patients prone to adverse outcomes.

TRIAL REGISTRATION

This study was registered at www.chictr.org.cn (registration number Chi CTR-2300070377).

Biomarkers in the intensive care setting: A focus on using procalcitonin and C-reactive protein to optimize antimicrobial duration of therapy

Managing the critically ill patient with infection is complex, requiring clinicians to synthesize considerable information relating to antimicrobial efficacy and treatment duration. The use of biomarkers may play an important role in identifying variation in treatment response and providing information about treatment efficacy. Though a vast number of biomarkers for clinical application have been described, procalcitonin and C-reactive protein (CRP) are the most thoroughly investigated in the critically ill. However, the presence of heterogeneous populations, variable end points, and incongruent methodology in the literature complicates the use of such biomarkers to guide antimicrobial therapy. This review focuses on an appraisal of evidence for use of procalcitonin and CRP to optimize antimicrobial duration of therapy (DOT) in critically ill patients. Procalcitonin-guided antimicrobial therapy in mixed critically ill populations with varying degrees of sepsis appears to be safe and might assist in reducing antimicrobial DOT. Compared to procalcitonin, fewer studies exist examining the impact of CRP on antimicrobial DOT and clinical outcomes in the critically ill. Procalcitonin and CRP have been insufficiently studied in many key intensive care unit populations, including surgical patients with concomitant trauma, renally insufficient populations, the immunocompromised, and patients with septic shock. We believe the available evidence is not strong enough to warrant routine use of procalcitonin or CRP to guide antimicrobial DOT in critically ill patients with infection. So long as its limitations are recognized, procalcitonin could be considered to tailor antimicrobial DOT on a case-by-case basis in the critically ill patient.

CD4+ T cells related to disease severity in elderly and frailty community-acquired pneumonia patients: A retrospective cohort study

BACKGROUNDS

Elderly and frailty individuals show a more senescent immune system, which may relate to worse outcome in community-acquired pneumonia (CAP). This study aimed to explore prognostic factors related to immune.

METHODS

Sixty of elderly (≥65 years) and frailty (clinical frailty scale ≥5 scores) nonsevere CAP patients and 60 severe CAP (SCAP) patients were recruited at our center. Clinical and laboratory data, and several assessment scores were collected.

RESULTS

Compared with nonsevere CAP group, the elderly and frailty SCAP patients showed higher level of BMI, PaCO2 and lactate in arterial blood-gas, CURB-65 score, ICU admission, mechanical ventilation, shock accidence, and longer hospital stay using two-tailed t test. The SCAP group also showed increased CRP, IL-6, and PCT, and decreased CD3+ T cells, CD4+ T cells, and CD8+ T cells. Logistic regression analysis showed that CD4+ T cells, IL-6 and PCT were independent prognostic factors for SCAP. The area under the receiver operating characteristic (ROC) curve for CD4+ T cells combined with PCT was 0.771 (95% CI 0.683-0.859), and the sensitivity and specificity were both 76.7%. Paired t test analysis showed that low CD4+ T cells in SCAP patients increased after treatment.

CONCLUSIONS

CD4+ T cells decreased in elderly and frailty SCAP patients, and CD4+ T cells combined with PCT were relatively accurate in the prediction of elderly and frailty SCAP.

The role of proadrenomedullin, interleukin 6 and CD64 in the diagnosis and prognosis of septic shock

INTRODUCTION

Sepsis and septic shock are disorders of tissue perfusion and microcirculation associated with increased mortality. The role of biomarkers such as proadrenomedullin (PRO-ADM), interleukin 6 (IL-6) and neutrophil CD64 (CD64) in the diagnosis and prognosis of septic shock has been studied.

METHODS

GCS, SOFA score, APACHE 2 score, lactate, CRP, procalcitonin, PRO-ADM, IL-6, CD64 level and 28-day mortality were evaluated in patients with septic shock followed-up in the intensive care unit of Marmara University Hospital between July 2021 and December 2021. The study was planned as prospective, non-drug clinical research Committee.

RESULTS

There were no statistically significant differences between patient groups in gender, BMI, and presence of comorbidities (p > 0.05). The alive patient group had significantly higher GCS values and lower SOFA, APACHE 2, lactate and CD64 values than the dead patient group (p < 0.01). The cut-off values of laboratory parameters were determined using ROC analysis to predict mortality, SOFA and CD64 had high AUC. This is also a good indicator for mortality.The multivariate logistic regression model was estimated using the backward selection method. The mortality of ICU patients was predicted by a SOFA-value ≥ 12 (OR (95%CI) = 56.13 (5.44-578.64)), CD64 value ≥ 28.54 (OR (95% CI) = 23.78 (2.61-216.85)), and ADM-value ≥ 86.79 (OR (95% CI) = 15.86 (1.02-246.49)) (p < 0.05) .

CONCLUSION

In conclusion, serum CD64 level, PRO-ADM level, and SOFA score proved to be effective parameters for predicting prognosis and mortality in septic shock. However, IL-6 proved to be a weak biomarker and failed to predict mortality. CD64, which is easier and more practical to use, can be used instead of the SOFA score.

Biomarker-Based Assessment Model for Detecting Sepsis: A Retrospective Cohort Study

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.

Development and Validation of a Rapid and Efficient Prognostic Scoring System for Sepsis Based on Oxygenation Index, Lactate and Glasgow Coma Scale

Objective

To develop a concise scoring system for efficient and rapid assessment of sepsis prognosis applicable to emergency departments.

Methods

This was a single-center retrospective cohort study of patients with sepsis. In this study, a new scoring system (oxygenation index, lactate, and Glasgow coma scale: GOL) was developed through a derivation group, and then the GOL was validated using a validation group. Multivariate logistic regression analysis was performed to investigate the relationship between GOL and 28-day adverse outcomes. The GOL was compared with the previous scoring system using receiver operating characteristic curves (ROC) and decision analysis curves. The endpoints of this study were mortality, mechanical ventilation (MV), and admission to the intensive care unit (AICU).

Results

608 patients were included in the derivation group and 213 patients in the validation group, with 131 and 42 deaths, respectively. In the validation group, lactate (Lac), oxygenation index (PaO₂/FiO₂), and Glasgow coma scale score (GCS), the three best performers in predicting 28-day mortality from receiver operating characteristic curves, were used to construct the GOL. The higher the GOL score, the higher the incidence of death, MV and AICU within 28 days. Multifactorial logistic regression analysis showed that when the GOL was greater than 1, it was an independent risk factor for 28-day mortality, MV, and AICU. In predicting 28-day mortality, GOL was superior to the quick Sequential Organ Failure Assessment (qSOFA), Mortality in Emergency Department Sepsis Score (MEDS), Systemic Inflammatory Response Syndrome Score (SIRS), and Modified Early Warning Score (MEWS), and was comparable to the Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA).

Conclusion

The GOL is a simple, rapid, and accurate method for early identification of patients at increased risk of in-hospital death from sepsis.

Monitoring Macro- and Microcirculation in the Critically Ill: A Narrative Review

Circulatory shock is a common and important diagnosis in the critical care environment. Hemodynamic monitoring is quintessential in the management of shock. The currently used hemodynamic monitoring devices not only measure cardiac output but also provide data related to the prediction of fluid responsiveness, extravascular lung water, and also pulmonary vascular permeability. Additionally, these devices are minimally invasive and associated with fewer complications. The area of hemodynamic monitoring is progressively evolving with a trend toward the use of minimally invasive devices in this area. The critical care physician should be well-versed with current hemodynamic monitoring limitations and stay updated with the upcoming advances in this field so that optimal therapy can be delivered to patients in circulatory shock.

Fluid Therapy for Critically Ill Adults With Sepsis: A Review

Importance

Approximately 20% to 30% of patients admitted to an intensive care unit have sepsis. While fluid therapy typically begins in the emergency department, intravenous fluids in the intensive care unit are an essential component of therapy for sepsis.

Observations

For patients with sepsis, intravenous fluid can increase cardiac output and blood pressure, maintain or increase intravascular fluid volume, and deliver medications. Fluid therapy can be conceptualized as 4 overlapping phases from early illness through resolution of sepsis: resuscitation (rapid fluid administered to restore perfusion); optimization (the risks and benefits of additional fluids to treat shock and ensure organ perfusion are evaluated); stabilization (fluid therapy is used only when there is a signal of fluid responsiveness); and evacuation (excess fluid accumulated during treatment of critical illness is eliminated). Among 3723 patients with sepsis who received 1 to 2 L of fluid, 3 randomized clinical trials (RCTs) reported that goal-directed therapy administering fluid boluses to attain a central venous pressure of 8 to 12 mm Hg, vasopressors to attain a mean arterial blood pressure of 65 to 90 mm Hg, and red blood cell transfusions or inotropes to attain a central venous oxygen saturation of at least 70% did not decrease mortality compared with unstructured clinical care (24.9% vs 25.4%; P = .68). Among 1563 patients with sepsis and hypotension who received 1 L of fluid, an RCT reported that favoring vasopressor treatment did not improve mortality compared with further fluid administration (14.0% vs 14.9%; P = .61). Another RCT reported that among 1554 patients in the intensive care unit with septic shock treated with at least 1 L of fluid compared with more liberal fluid administration, restricting fluid administration in the absence of severe hypoperfusion did not reduce mortality (42.3% vs 42.1%; P = .96). An RCT of 1000 patients with acute respiratory distress during the evacuation phase reported that limiting fluid administration and administering diuretics improved the number of days alive without mechanical ventilation compared with fluid treatment to attain higher intracardiac pressure (14.6 vs 12.1 days; P < .001), and it reported that hydroxyethyl starch significantly increased the incidence of kidney replacement therapy compared with saline (7.0% vs 5.8%; P = .04), Ringer lactate, or Ringer acetate.

Conclusions and Relevance

Fluids are an important component of treating patients who are critically ill with sepsis. Although optimal fluid management in patients with sepsis remains uncertain, clinicians should consider the risks and benefits of fluid administration in each phase of critical illness, avoid use of hydroxyethyl starch, and facilitate fluid removal for patients recovering from acute respiratory distress syndrome.

Hypoperfusion context as a predictor of 28-d all-cause mortality in septic shock patients: A comparative observational study

BACKGROUND

As per the latest Surviving Sepsis Campaign guidelines, fluid resuscitation should be guided by repeated measurements of blood lactate levels until normalization. Nevertheless, raised lactate levels should be interpreted in the clinical context, as there may be other causes of elevated lactate levels. Thus, it may not be the best tool for real-time assessment of the effect of hemodynamic resuscitation, and exploring alternative resuscitation targets should be an essential research priority in sepsis.

AIM

To compare the 28-d mortality in two clinical patterns of septic shock: hyperlactatemic patients with hypoperfusion context and hyperlactatemic patients without hypoperfusion context.

METHODS

This prospective comparative observational study carried out on 135 adult patients with septic shock that met Sepsis-3 definitions compared patients with hyperlactatemia in a hypoperfusion context (Group 1, n = 95) and patients with hyperlactatemia in a non-hypoperfusion context (Group 2, n = 40). Hypoperfusion context was defined by a central venous saturation less than 70%, central venous-arterial PCO₂ gradient [P(cv-a)CO₂] ≥ 6 mmHg, and capillary refilling time (CRT) ≥ 4 s. The patients were observed for various macro and micro hemodynamic parameters at regular intervals of 0 h, 3 h, and 6 h. All-cause 28-d mortality and all other secondary objective parameters were observed at specified intervals. Nominal categorical data were compared using the χ² or Fisher’s exact test. Non-normally distributed continuous variables were compared using the Mann-Whitney U test. Receiver operating characteristic curve analysis with the Youden index determined the cutoff values of lactate, CRT, and metabolic perfusion parameters to predict the 28-d all-cause mortality. A P value of < 0.05 was considered significant.

RESULTS

Patient demographics, comorbidities, baseline laboratory, vital parameters, source of infection, baseline lactate levels, and lactate clearance at 3 h and 6 h, Sequential Organ Failure scores, need for invasive mechanical ventilation, days on mechanical ventilation, and renal replacement therapy-free days within 28 d, duration of intensive care unit stay, and hospital stay were comparable between the two groups. The stratification of patients into hypoperfusion and non-hypoperfusion context did not result in a significantly different 28-d mortality (24% vs 15%, respectively; P = 0.234). However, the patients within the hypoperfusion context with high P(cv-a)CO₂ and CRT (P = 0.022) at baseline had significantly higher mortality than Group 2. The norepinephrine dose was higher in Group 1 but did not achieve statistical significance with a P > 0.05 at all measured intervals. Group 1 had a higher proportion of patients requiring vasopressin and the mean vasopressor-free days out of the total 28 d were lower in patients with hypoperfusion (18.88 ± 9.04 vs 21.08 ± 8.76; P = 0.011). The mean lactate levels and lactate clearance at 3 h and 6 h, CRT, P(cv-a)CO₂ at 0 h, 3 h, and 6 h were found to be associated with 28-d mortality in patients with septic shock, with lactate levels at 6 h having the best predictive value (area under the curve lactate at 6 h: 0.845).

CONCLUSION

Septic shock patients fulfilling the hypoperfusion and non-hypoperfusion context exhibited similar 28-d all-cause hospital mortality, although patients with hypoperfusion displayed a more severe circulatory dysfunction. Lactate levels at 6 h had a better predictive value in predicting 28-d mortality than other parameters. Persistently high P(cv-a)CO₂ (> 6 mmHg) or increased CRT (> 4 s) at 3 h and 6 h during early resuscitation can be a valuable additional aid for prognostication of septic shock patients.

Team Approach: The Unstable Trauma Patient

» A multidisciplinary, integrated, and synergistic team approach to the unstable polytrauma patient is critical to optimize outcomes, minimize morbidity, and reduce mortality.» The use of Advanced Trauma Life Support protocols helps standardize the assessment and avoid missing critical injuries» Effective and open dialog with consulting specialists is paramount for effective team-based care.» Orthopaedic surgeons should play an important role in the rapid assessment of potentially life-threatening and/or limb-threatening injuries including pelvic ring disruption, open fractures with substantial blood loss, and dysvascular limbs.

Heterogeneity of surrogate outcome measures used in critical care studies: A systematic review

BACKGROUND

The choice of outcome measure is a critical decision in the design of any clinical trial, but many Phase III clinical trials in critical care fail to detect a difference between the interventions being compared. This may be because the surrogate outcomes used to show beneficial effects in early phase trials (which informed the design of the subsequent Phase III trials) are not valid guides to the differences between the interventions for the main outcomes of the Phase III trials. We undertook a systematic review (1) to generate a list of outcome measures used in critical care trials, (2) to determine the variability in the outcome reporting in the respiratory subgroup and (3) to create a smaller list of potential early phase endpoints in the respiratory subgroup.

METHODS

Data related to outcomes were extracted from studies published in the six top-ranked critical care journals between 2010 and 2020. Outcomes were classified into subcategories and categories. A subset of early phase endpoints relevant to the respiratory subgroup was selected for further investigation. The variability of the outcomes and the variability in reporting was investigated.

RESULTS

A total of 6905 references were retrieved and a total of 294 separate outcomes were identified from 58 studies. The outcomes were then classified into 11 categories and 66 subcategories. A subset of 22 outcomes relevant for the respiratory group were identified as potential early phase outcomes. The summary statistics, time points and definitions show the outcomes are analysed and reported in different ways.

CONCLUSION

The outcome measures were defined, analysed and reported in a variety of ways. This creates difficulties for synthesising data in systematic reviews and planning definitive trials. This review once again highlights an urgent need for standardisation and validation of surrogate outcomes reported in critical care trials. Future work should aim to validate and develop a core outcome set for surrogate outcomes in critical care trials.

Tissue oxygen saturation is predictive of lactate clearance in patients with circulatory shock

BACKGROUND

Tissue oxygen saturation (StO₂) decrease could appear earlier than lactate alteration. However, the correlation between StO₂ and lactate clearance was unknown.

METHODS

This was a prospective observational study. All consecutive patients with circulatory shock and lactate over 3 mmol/L were included. Based on the rule of nines, a BSA (body surface area) weighted StO₂ was calculated from four sites of StO₂ (masseter, deltoid, thenar and knee). The formulation was as follows: masseter StO₂ × 9% + (deltoid StO₂ + thenar StO₂) × (18% + 27%)/ 2 + knee StO₂ × 46%. Vital signs, blood lactate, arterial and central venous blood gas were measured simultaneously within 48 h of ICU admission. The predictive value of BSA-weighted StO₂ on 6-hour lactate clearance > 10% since StO₂ initially monitored was assessed.

RESULTS

A total of 34 patients were included, of whom 19 (55.9%) had a lactate clearance higher than 10%. The mean SOFA score was lower in cLac ≥ 10% group compared with cLac < 10% group (11 ± 3 vs. 15 ± 4, p = 0.007). Other baseline characteristics were comparable between groups. Compared to non-clearance group, StO₂ in deltoid, thenar and knee were significantly higher in clearance group. The area under the receiver operating curves (AUROC) of BSA-weighted StO₂ for prediction of lactate clearance (0.92, 95% CI [Confidence Interval] 0.82-1.00) was significantly higher than StO₂ of masseter (0.65, 95% CI 0.45-0.84; p < 0.01), deltoid (0.77, 95% CI 0.60-0.94; p = 0.04), thenar (0.72, 95% CI 0.55-0.90; p = 0.01), and similar to knee (0.87, 0.73-1.00; p = 0.40), mean StO₂ (0.85, 0.73-0.98; p = 0.09). Additionally, BSA-weighted StO₂ model had continuous net reclassification improvement (NRI) over the knee StO₂ and mean StO₂ model (continuous NRI 48.1% and 90.2%, respectively). The AUROC of BSA-weighted StO₂ was 0.91(95% CI 0.75-1.0) adjusted by mean arterial pressure and norepinephrine dose.

CONCLUSIONS

Our results suggested that BSA-weighted StO₂ was a strong predictor of 6-hour lactate clearance in patients with shock.

AACC Guidance Document on the Clinical Use of Procalcitonin

BACKGROUND

Procalcitonin (PCT), a peptide precursor of the hormone calcitonin, is a biomarker whose serum concentrations are elevated in response to systemic inflammation caused by bacterial infection and sepsis. Clinical adoption of PCT in the United States has only recently gained traction with an increasing number of Food and Drug Administration-approved assays and expanded indications for use. There is interest in the use of PCT as an outcomes predictor as well as an antibiotic stewardship tool. However, PCT has limitations in specificity, and conclusions surrounding its utility have been mixed. Further, there is a lack of consensus regarding appropriate timing of measurements and interpretation of results. There is also a lack of method harmonization for PCT assays, and questions remain regarding whether the same clinical decision points may be used across different methods.

CONTENT

This guidance document aims to address key questions related to the use of PCT to manage adult, pediatric, and neonatal patients with suspected sepsis and/or bacterial infections, particularly respiratory infections. The document explores the evidence for PCT utility for antimicrobial therapy decisions and outcomes prediction. Additionally, the document discusses analytical and preanalytical considerations for PCT analysis and confounding factors that may affect the interpretation of PCT results.

SUMMARY

While PCT has been studied widely in various clinical settings, there is considerable variability in study designs and study populations. Evidence to support the use of PCT to guide antibiotic cessation is compelling in the critically ill and in some lower respiratory tract infections but is lacking in other clinical scenarios, and evidence is also limited in the pediatric and neonatal populations. Interpretation of PCT results requires guidance from multidisciplinary care teams of clinicians, pharmacists, and clinical laboratorians.

Emerging concepts in the care of patients with cirrhosis and septic shock

Septic shock impacts approximately 6% of hospitalized patients with cirrhosis and is associated with high rates of morbidity and mortality. Although a number of landmark clinical trials have paved the way for incremental improvements in the diagnosis and management of septic shock in the general population, patients with cirrhosis have largely been excluded from these studies and critical knowledge gaps continue to impact the care of these individuals. In this review, we discuss nuances in the care of patients with cirrhosis and septic shock using a pathophysiology-based approach. We illustrate that septic shock may be challenging to diagnose in this population in the context of factors such as chronic hypotension, impaired lactate metabolism, and concomitant hepatic encephalopathy. Furthermore, we demonstrate that the application of routine interventions such as intravenous fluids, vasopressors, antibiotics, and steroids should be carefully considered among those with decompensated cirrhosis in light of hemodynamic, metabolic, hormonal, and immunologic disturbances. We propose that future research should include and characterize patients with cirrhosis in a systematic manner, and clinical practice guidelines may need to be refined accordingly.

Serial evaluation of the serum lactate level with the SOFA score to predict mortality in patients with sepsis

In patients with sepsis, outcome prediction plays an important role in influencing therapeutic decision making. In this nationwide, prospective, observational cohort study of sepsis patients conducted between September 2019 and December 2020, we evaluated a novel scoring system using serial Sequential Organ Failure Assessment (SOFA) scores and serum lactate to accurately predict mortality in sepsis. Based on the serum lactate score (Lac-score), patients were assigned to 5 categories: lactate < 2, ≥ 2 to < 4, ≥ 4 to < 8, ≥ 8 to < 12, and ≥ 12 mmol/L. Lac-SOFA score was defined as the sum of Lac-score and SOFA score. After screening 7113 patients, 379 were excluded and 6734 were included in analysis. In-hospital mortality AUROC for serial Lac-SOFA score from initial to ICU day 3 was significantly higher than that for serial SOFA score (initial, 0.679 vs. 0.656, day 1, 0.723 vs. 0.709, day 2, 0.760 vs. 0.747, and day 3, 0.797 vs. 0.781; DeLong's test, p < 0.001). The initial Lac-SOFA score significantly correlated with in-hospital mortality when the patients were divided into five classes based on 5-point intervals (p < 0.05). Serial evaluation of lactate levels with the SOFA score may improve the predictive accuracy of the SOFA score for determining mortality risk in sepsis patients.

Norepinephrine dose, lactate or heart rate: what impacts prognosis in sepsis and septic shock? Results from a prospective, monocentric registry

OBJECTIVE

The study comprehensively investigates the prognostic value of norepinephrine (NE) dose, lactate and heart rate in patients with sepsis and septic shock.

BACKGROUND

Limited data regarding the prognostic value of NE dose, lactate and heart rate in patients meeting the sepsis-3 criteria is available.

METHODS

Consecutive patients with sepsis and septic shock from 2019 to 2021 were included. The prognostic value of NE dose, lactate and heart rate was tested for 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman's correlations, C-statistics, Kaplan-Meier analyses, as well as one-factorial repeated measures analysis of variance (ANOVA) and Cox proportional regression analyses.

RESULTS

339 patients with sepsis or septic shock were included. With an area under the curve (AUC) of up to 0.638 and 0.685, NE dose and lactate revealed moderate prognostic accuracy for 30-day all-cause mortality, whereas heart rate was not associated with prognosis. Very high NE doses (i.e. > 1.0 mcg/kg/min) (HR = 2.938; 95% CI 1.933 - 4.464; p = .001) and lactate levels (i.e. ≥ 4 mmol/l) (HR = 2.963; 95% CI 2.095 - 4.191; p = .001) on admission were associated with highest risk of death. Finally, increasing NE doses and lactate levels from day 1 to 3 indicated increased risk of death, which was consistent after multivariable adjustment.

CONCLUSION

Both very high NE doses and lactate levels - but not heart rate - were associated with increased risk of 30-d all-cause mortality in patients with sepsis and septic shock.

Sustained Perturbation of Metabolism and Metabolic Subphenotypes Are Associated With Mortality and Protein Markers of the Host Response

Perturbed host metabolism is increasingly recognized as a pillar of sepsis pathogenesis, yet the dynamic alterations in metabolism and its relationship to other components of the host response remain incompletely understood. We sought to identify the early host-metabolic response in patients with septic shock and to explore biophysiological phenotyping and differences in clinical outcomes among metabolic subgroups.

DESIGN

We measured serum metabolites and proteins reflective of the host-immune and endothelial response in patients with septic shock.

SETTING

We considered patients from the placebo arm of a completed phase II, randomized controlled trial conducted at 16 U.S. medical centers. Serum was collected at baseline (within 24 hr of the identification of septic shock), 24-hour, and 48-hour postenrollment. Linear mixed models were built to assess the early trajectory of protein analytes and metabolites stratified by 28-day mortality status. Unsupervised clustering of baseline metabolomics data was conducted to identify subgroups of patients.

PATIENTS

Patients with vasopressor-dependent septic shock and moderate organ dysfunction that were enrolled in the placebo arm of a clinical trial.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Fifty-one metabolites and 10 protein analytes were measured longitudinally in 72 patients with septic shock. In the 30 patients (41.7%) who died prior to 28 days, systemic concentrations of acylcarnitines and interleukin (IL)-8 were elevated at baseline and persisted at T24 and T48 throughout early resuscitation. Concentrations of pyruvate, IL-6, tumor necrosis factor-α, and angiopoietin-2 decreased at a slower rate in patients who died. Two groups emerged from clustering of baseline metabolites. Group 1 was characterized by higher levels of acylcarnitines, greater organ dysfunction at baseline and postresuscitation (p < 0.05), and greater mortality over 1 year (p < 0.001).

CONCLUSIONS

Among patients with septic shock, nonsurvivors exhibited a more profound and persistent dysregulation in protein analytes attributable to neutrophil activation and disruption of mitochondrial-related metabolism than survivors.

Implementing Pediatric Surviving Sepsis Campaign Guidelines: Improving Compliance With Lactate Measurement in the PICU

The 2020 pediatric Surviving Sepsis Campaign (pSSC) recommends measuring lactate during the first hour of resuscitation for severe sepsis/shock. We aimed to improve compliance with this recommendation for patients who develop severe sepsis/shock while admitted to the PICU.

DESIGN

Structured, quality improvement initiative.

SETTING

Single-center, 26-bed, quaternary-care PICU.

PATIENTS

All patients with PICU-onset severe sepsis/shock from December 2018 to December 2021.

INTERVENTIONS

Creation of a multidisciplinary local sepsis improvement team, education program targeting frontline providers (nurse practitioners, resident physicians), and peer-to-peer nursing education program with feedback to key stakeholders.

MEASUREMENTS AND MAIN RESULTS

The primary outcome measure was compliance with obtaining a lactate measurement within 60 minutes of the onset of severe sepsis/shock originating in our PICU using a local Improving Pediatric Sepsis Outcomes database and definitions. The process measure was time to first lactate measurement. Secondary outcomes included number of IV antibiotic days, number of vasoactive days, number of ICU days, and number of ventilator days. A total of 166 unique PICU-onset severe sepsis/shock events and 156 unique patients were included. One year after implementation of our first interventions with subsequent Plan-Do-Study-Act cycles, overall compliance increased from 38% to 47% (24% improvement) and time to first lactate decreased from 175 to 94 minutes (46% improvement). Using a statistical process control I chart, the preshift mean for time to first lactate measurement was noted to be 179 minutes and the postshift mean was noted to be 81 minutes demonstrating a 55% improvement.

CONCLUSIONS

This multidisciplinary approach led to improvement in time to first lactate measurement, an important step toward attaining our target of lactate measurement within 60 minutes of septic shock identification. Improving compliance is necessary for understanding implications of the 2020 pSSC guidelines on sepsis morbidity and mortality.

Early Recognition and Risk Stratification in Cardiogenic Shock: Well Begun Is Half Done

Cardiogenic shock is a complex syndrome manifesting with distinct phenotypes depending on the severity of the primary cardiac insult and the underlying status. As long as therapeutic interventions fail to divert its unopposed rapid evolution, poor outcomes will continue challenging health care systems. Thus, early recognition in the emergency setting is a priority, in order to avoid delays in appropriate management and to ensure immediate initial stabilization. Since advanced therapeutic strategies and specialized shock centers may provide beneficial support, it seems that directing patients towards the recently described shock network may improve survival rates. A multidisciplinary approach strategy commands the interconnections between the strategic role of the ED in affiliation with cardiac shock centers. This review outlines critical features of early recognition and initial therapeutic management, as well as the utility of diagnostic tools and risk stratification models regarding the facilitation of patient trajectories through the shock network. Further, it proposes the implementation of precise criteria for shock team activation and the establishment of definite exclusion criteria for streaming the right patient to the right place at the right time.

Fluids and vasopressors in septic shock: basic knowledge for a first approach in the emergency department

Much research, both pathophysiological and clinical, has been produced about septic shock during the last 20 years. Nevertheless, many aspects of treatment are still controversial, among these the approach to the administration of fluids and vasopressors. After the first clinical trial on Early goal-directed therapy (EGDT) was published, a liberal approach to the use of fluids and conservative use of vasopressors prevailed, but in recent years a more restrictive use of fluids and an earlier introduction of vasopressors seem to be preferred. Although both treatments are based on sound pathophysiological knowledge,  clinical evidence is still inadequate and somehow controversial.  In this non-systematic review, recent research on the hemodynamics of septic shock and its treatment with fluids and inotropes is discussed. As a conclusion, general indications are proposed for a practical approach to patients in septic shock.

The prognostic value of delta-lactate in critically ill children

AIM

This study aimed to test delta-lactate (ΔL) as a short-term risk stratification method in critically ill children.

METHODS

An exploratory study of patients admitted to paediatric intensive care unit (PICU) was conducted. ΔL was calculated as the difference between the maximum lactate concentrations on Days 1 and 2. According to the ΔL cutoff, two groups were considered: low mortality risk (LMR) - ΔL ≥ 0.05 mmol/L - and high mortality risk (HMR) - ΔL < 0.05 mmol/L.

RESULTS

Mortality, both during PICU stay and at 28 days, was statistically associated with elevated serum lactate on D1 and D2, per se. For the 93 cases with elevated lactate on Day 1, and a ΔL cutoff of 0.05 mmol/L, the area under the ROC curve was 0.698 (95% confidence interval, 0.47-0.93). HMR patients scored higher PIM3, were not discharged home until 28 days, counted fewer ventilation-free days and needed renal replacement therapy more often.

CONCLUSION

Elevated lactate levels at admission, as well as applying the optimal cutoff for ΔL, allowed to predict short-term mortality: if an increase or minimal decrease in lactate maximum levels occurred from D1 to D2, death was almost eight times more probable. In critically ill children, delta-lactate predicts short-term outcome.