Brief report: Serial capillary lactate measurement predict the evolution of early sepsis

OBJECTIVE

In intensive care settings, blood lactate level measurement proved to be an excellent predictor of outcomes. In patients requiring less urgent treatment, the arterial blood lactate is less sensitive and its usefulness remains to be proven. Capillary blood lactate dosing, an emergent point-of-care technique readily available should be more sensitive to changes in these settings.

METHOD

prospective, observational, monocentric study conducted in a polyvalent internal medicine ward in a French University Hospital. The inclusion criteria were the existence of new symptoms of abrupt onset in an otherwise stable patient. All the patients had a point of care measurement of baseline capillary and venous lactate levels (EDGE, ApexBio) and standardized control before any therapeutic means were initiated. A follow-up test was performed once again within 12 to 36 hours. All the patients received standard medical care adapted to their condition. The primary outcomes were considered dying within 30 days or requiring intensive care or invasive therapeutic procedures.

RESULTS

13 patients were analyzed. Seven patients reached the composite outcome with 3 deaths. The superimposed complication proved to be infectious in every case. The median lactate levels were at baseline (mmol/ l): capillary Mc0=5.2(2.16), venous Mv0=2.3(2.0) and arterial Ma0=1.8(1.7) and at follow-up (mmol/ l) capillary: Mc1=3.3(1.1), venous Mv1=1.8(1.8) and arterial Ma1=1.3(0.7). In nonparametric analysis, the absence of normalization of capillary lactate at follow-up was correlated well with poor outcomes (p=.05). This was not the case of arterial or venous lactate measurements. The positive lactate clearance was present in the majority of patients (83.3%) but it did not predict the outcomes (p=.435) and there was no correlation between the baseline lactate and the clinical outcome (p>.05).

CONCLUSION

In non intensive care settings, capillary lactate level could be a more sensitive method than the classical lactate measurement for predicting the outcomes of acute conditions, especially infectious. A persistently high lactate level rather than its initial value or clearance seems to correlate better with poorer outcomes.

ABBREVIATIONS

SSC = Surviving sepsis campaign, ED = Emergency department, ICU = intensive care unit, , POC = Point of care, ICC = inter class coefficient.

Transradial coronary catheterization and intervention across the whole spectrum of Allen test results

OBJECTIVES

The aim of this study was to investigate the safety and feasibility of transradial coronary catheterization across the whole spectrum of Allen test (AT) results.

BACKGROUND

Whether the AT can predict ischemic complications after transradial access (TRA) is controversial. No prospective assessment exists on the safety and feasibility of TRA across the whole spectrum of AT results.

METHODS

From October 2007 to June 2009, a total of 942 patients undergoing TRA were screened, and 203 were recruited, of whom 83, 60, and 60 had normal, intermediate, and abnormal AT results, respectively. Patients underwent serial assessments of thumb capillary lactate (the primary endpoint), thumb plethysmography, and ulnar frame count to investigate the patency of the ulnopalmar arches, as well as handgrip strength tests to examine the isometric strength of the hand and forearm muscles and discomfort ratings.

RESULTS

Lactate did not differ among the 3 study groups after the procedure (1.85 ± 0.93 mmol/l in patients with normal AT results, 1.85 ± 0.66 mmol/l in those with intermediate results, and 1.97 ± 0.71 mmol/l in those with abnormal results; p = 0.59) or at other time points during the study. Plethysmographic readings showed improvements of ulnopalmar collateralization in patients with non-normal AT results, whereas the ulnar frame count was decreased, suggesting enhanced ulnar flow, in patients with abnormal AT results after TRA. Handgrip strength test results and discomfort ratings did not differ across AT groups. No hand ischemic complications occurred.

CONCLUSIONS

This study provides proof of concept for a paradigm shift in cardiovascular intervention, suggesting the safety and feasibility of TRA across the whole spectrum of AT results. Given the multiple implications of our findings, a broader clinical validation is needed. (Predictive Value of Allen's Test Result in Elective Patients Undergoing Coronary Catheterization Through Radial Approach [RADAR]; NCT00597324).