The Effect of Lactate and Lactate Clearance on Mortality in Sepsis Patients Admitted to the Emergency Department

Year 2022, Volume: 4 Issue: 1, 5 - 12, 01.03.2022

Duha Tuba Şeyhoğlu Yonca Senem Akdeniz Afşın İpekci İbrahim İkizceli

https://doi.org/10.38175/phnx.1004552

Abstract

Objective
Early prognosis of sepsis, which affects millions of people all over the world every year and can have a mortality of more than 25%, is very important especially for emergency services where patients spend their most critical golden hours. Lactate and lactate clearance are also potential marker candidates that can be used to predict mortality, which has now started to take place in sepsis guidelines. The aim of this study is to investigate the power of lactate and lactate clearance to predict mortality in sepsis.
Material and Method
All patients over the age of 18 with a diagnosis of severe sepsis and septic shock who presented to the emergency department during a one-year period were included in this prospective observational cohort study. The lactate clearance was calculated by taking the blood gases of the patients at the time of admission and six hours later, and evaluated in terms of predicting mortality along with other parameters.
Results
The decrease in lactate values at the sixth hour of 90 patients included in the study was found to be statistically significant (p=0.001). A positive and significant correlation was found between the lactate values of the patients at admission and mortality (p=0.046). A negative significant correlation was found between lactate clearance of the patients and mortality (p=0.001).
Conclusion
In patients with sepsis, the lactate value is important in determining mortality and prognosis. Regardless of arrival lactate value, the high rate of lactate reduction at the sixth hour indicates a good prognosis. In addition, it was determined that the sixth hour lactate value also had an effect on predicting mortality. When all these results are taken into consideration, it can be said that the lactate value and lactate clearance are useful predictors of prognosis in sepsis patients admitted to the emergency department. However, they are not sufficient on their own to determine the prognosis and should be used together with other markers and clinical evaluation.

Keywords

emergency room, lactate, lactate clearance, sepsis

Acil Servise Başvuran Sepsis Hastalarında Laktat ve Laktat Klirensinin Mortaliteye Etkisi

Abstract

Amaç
Her yıl tüm dünyada milyonlarca insanı etkileyen ve mortalitesi %25’ten fazla olabilen sepsisin erken dönemde prognoz tayini özellikle hastaların en kritik altın saatlerini geçirdikleri acil servisler için çok önemlidir. Laktat ve laktat klirensi de artık sepsis kılavuzlarında yerini almaya başlamış mortalite öngörmede kullanılabilecek potansiyel belirteç adaylarındandırlar. Bu çalışmanın amacı laktat ve laktat klirensinin sepsiste mortaliteyi öngörme gücünün araştırılmasıdır.
Gereç ve Yöntem
Bu prospektif gözlemsel kohort çalışmasına bir yıllık dönemde acil servise başvuran 18 yaş üzeri tüm ağır sepsis ve septik şok tanılı hastalar dâhil edilmiştir. Hastaların başvuru sırasında ve altı saat sonra kan gazı alınarak laktat klirensi hesaplanmış ve diğer parametreler ile birlikte mortaliteyi öngörme açısından değerlendirilmiştir.
Bulgular
Çalışmaya alınan 90 hastanın altıncı saatteki laktat değerlerindeki düşme istatistiksel olarak anlamlı bulunmuştur (p=0.001). Hastaların başvurudaki laktat değerleri ile mortalite arasında pozitif yönde anlamlı ilişki saptanmıştır (p=0.046). Hastaların laktat klirensleri ile mortalite arasında negatif yönde anlamlı ilişki saptanmıştır (p=0.001).
Sonuç
Sepsis hastalarında geliş laktat değerinin mortalite ve prognozu belirlemede önemi vardır. Geliş laktat değerinden bağımsız olarak altıncı saatte laktatın düşme oranının yüksekliği iyi prognozu gösterir. Ayrıca altıncı saat laktat değerinin de mortaliteyi öngörmede etkisi olduğu belirlenmiştir. Tüm bu sonuçlar göze alındığında geliş laktat değerinin ve laktat klirensinin acil servise gelen sepsis hastalarında prognozu göstermede yararlı belirteçler olduğu söylenebilir. Ancak prognozu belirlemede tek başlarına yeterli değildirler, diğer belirteçler ve klinik değerlendirme ile beraber kullanılmalıdırlar.

Keywords

acil servis, laktat, laktat klirensi, sepsis

References

• Singer M, Deutschman CS, Seymour C, Shankar-Hari M, Annane D, Bauer M et al. The third ınternational consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801-810.
• Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. CritCareMed 2013; 41:580.
• Innocenti F, Bianchi S, Guerrini E, Vicidomini S, Conti A, Zanobetti M et al. Prognostic scores for early stratification of septic patients admitted to an emergency department-high dependency unit; European Journal of Emergency Medicine. 2014;21:254-259.
• Bas de Groota, de Deckere ERJT, Flameling R, Sandel MH, Vis A. et al. Performance of illness severity scores to guide disposition of emergency department patients with severe sepsis or septic shock; European Journal of Emergency Medicine. 2012;19:316-322.
• Shapiro NI, Wolfe RE, Moore RB, Smith EBA, Burdick E, Bates DW. Mortality in Emergency Department Sepsis (MEDS) score: A prospectively derived and validated clinical prediction rule. Crit Care Med. 2003;31:670-675.
• Macdonald SPJ, Arendts G, Fatovich DM, Simon GA, Brown SGA. Comparison of PIRO, SOFA, and MEDS Scores for predicting mortality in emergency department patients with severe sepsis and septic shock; Academic Emergency Medicine. 2014;21:1257-1263.
• Nguyen HB, van Ginkel C, Batech M, Banta J, Corbett SW. Comparison of predisposition, ınsult/ınfection, response, and organ dysfunction, acute physiology and chronic health evaluation II, and Mortality in emergency department sepsis in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle; Journal of Critical Care. 2012;27:362-369.
• Moreno RP, Metnitz B, Adler L, Hoechtl A, Bauer P, Metnitz PGH et al. Sepsis mortality prediction based on predisposition, infection and response; Intensive Care Med. 2008;34:496-504.
• Li C. Risk stratification and prognostic performance of the predisposition, infection, response, and organ dysfunction (PIRO) scoring system in septic patients in the emergency department: a cohortstudy Critical Care. 2014;18:R74.
• Jones AE, Trzeciak S, and Kline JA. The sequential organ failure assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation. Crit Care Med. 2009;37(5):1649-1654.
• Osborn TM, Osborn, Gary P, Stanley L, Townsend S, Schorr CA, Levy MM, Dellinger RP et al. Sepsis severity score: An Internationally derived scoring system from the surviving sepsis campaign database. Crit Care Med. 2014;42:1969-1976.
• Shankar-Hari M, Phillips GS, Levy ML, Seymour CW, Liu WX, Deutchman CS et al. Developing a New definition and assessing new clinical criteria for septic shock: For the third ınternational consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315:775.
• Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of clinical criteria for sepsis: for the third ınternational consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315:762.
• Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368.
• Vincent J-L, Quintairos e Silva A, Couto L, Taccone FS. The value of blood lactate kinetics in critically ill patients: A systematic review. Crit Care. 2016;20(1):1-14.
• Marty P, Roquilly A, Vallée F, Luzi A, Ferre F, Fourcade O et al. Lactate clearance for death prediction in severe sepsis or septic shock patients during the first 24 hours in Intensive Care Unit: an observational study. Ann. Intensive Care. 2013;3(3):1-7.
• Jansen TC, van Bommel J, Schoonderbeek FJ, Sleeswijk Visser SJ, van der Klooster JM, Lima AP et al. Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial. Am J Respir Crit Care Med. 2010;15;182(6):752-761.
• Levraut J, Ichai C, Petit I, Ciebiera JP, Perus O, Grimaud D. Low exogenous lactate clearance as an early predictor of mortality in normolactatemic critically ill septic patients. Critical Care Medicine. 2003;31(3):705-710.
• Mikkelsen ME, Miltiades AN, Gaieski DF, Goyal M, Fuchs BD, Shah C et al. Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock. Critical Care Medicine. 2009;37(5):1670-1677.
• Nguyen HB, Rivers EP, Knoblich BP, Jacobsen G, Muzzin A, Ressler JA et al. Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Critical Care Medicine. 2004;32(8):1637-1642.
• Larkin CM, Santos-Martinez MJ, Ryan T, Radomski MW. Sepsis-associated thrombocytopenia. Thrombosis Research. 2016;141:11-16.
• Zhai R, Sheu CC, Su L, Gong MN, Tejera P, Chen F et al. Serum bilirubin levels on ICU admission are associated with ARDS development and mortality in sepsis. Thorax. 2009;64:784-790.
• Engel C, Brunkhorst FM, Bone HG, Brunkhorst R, Gerlach H, Grond S et al. Epidemiology of sepsis in Germany: results from a national prospective multicenter study. Intensive Care Med. 2007;33:606-618.
• Clemmer TP, Fisher CJ Jr, Bone RC, Slotman GJ, Metz CA, Thomas FO. Hypothermia in the sepsis syndrome and clinical outcome. The Methylprednisolone Severe Sepsis Study Group. Crit Care Med. 1992;20(10):1395-1401.
• Haas SA, Lange T, Saugel B, Petzoldt M, Fuhrmann V, Metschke M. Severe hyperlactatemia, lactate clearance and mortality in unselected critically ill patients. Intensive Care Med. 2016; 42:202-210.
• Ryoo SM, Lee JB, Lee YS, Lee JH, Lim KS, Jin Won Huh JW. Lactate level versus lactate clearance for predicting mortality in patients with septic shock defined by Sepsis-3. Critical Care Medicine. 2018;46(6):e489-495.
• Gu WJ, Zhang Z, Bakker J. Early lactate clearance-guided therapy in patients with sepsis: a meta-analysis with trial sequential analysis of randomized controlled trials. Intensive Care Med. 2015; 41(10):1862-1863.
• Pan J, Peng M, Liao C, Hu X, Wang A, Li X. Relative efficacy and safety of early lactate clearance-guided therapy resuscitation in patients with sepsis. Medicine. 2019; 98:98.
• Hernandez G, Bellomo R, Bakker J. The ten pitfalls of lactate clearance in sepsis. Intensive Care Med. 2019;45:82-85.