Dynamic lactate indices as predictors of outcome in critically ill patients

Critical Care

Rinaldo Bellomo³  David James Cooper⁷  Michael C Reade⁵  Edward Stachowski⁴  Craig French⁶  Ville Pettila¹  Moritoki Egi²  Michael Bailey¹  Alistair Nichol⁷ 

[1] Australian and New Zealand Intensive Care - Research Centre, School of Public Health and Preventive Medicine, Monash University, Commercial Road, Melbourne, VIC, Australia;Department of Anaesthesiology and Resuscitology, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama, Japan;Faculty of Medicine, University of Melbourne, Swanston Street, Melbourne, VIC, Australia;Department of Intensive Care, Westmead Hospital, Darcy Road, Sydney, NSW, Australia;Department of Intensive Care, The Austin Hospital, Heidelberg Road, Melbourne, VIC, Australia;Department of Intensive Care, The Western Hospital, Gordon Street, Melbourne, VIC, Australia;Department of Intensive Care, The Alfred Hospital, Commercial Road, Melbourne, VIC, Australia

关键词: mortality;    critical illness;    intensive care unit;    dynamic;    hyperlactaemia;    lactate;   

Others  :  1093652
DOI  :  10.1186/cc10497

 received in 2011-05-09, accepted in 2011-10-20,  发布年份 2011

【 摘 要 】

Introduction

Dynamic changes in lactate concentrations in the critically ill may predict patient outcome more accurately than static indices. We aimed to compare the predictive value of dynamic indices of lactatemia in the first 24 hours of intensive care unit (ICU) admission with the value of more commonly used static indices.

Methods

This was a retrospective observational study of a prospectively obtained intensive care database of 5,041 consecutive critically ill patients from four Australian university hospitals. We assessed the relationship between dynamic lactate values collected in the first 24 hours of ICU admission and both ICU and hospital mortality.

Results

We obtained 36,673 lactate measurements in 5,041 patients in the first 24 hours of ICU admission. Both the time weighted average lactate (LAC_TW24) and the change in lactate (LAC_Δ24) over the first 24 hours were independently predictive of hospital mortality with both relationships appearing to be linear in nature. For every one unit increase in LAC_TW24 and LAC_Δ24 the risk of hospital death increased by 37% (OR 1.37, 1.29 to 1.45; P < 0.0001) and by 15% (OR 1.15, 1.10 to 1.20; P < 0.0001) respectively. Such dynamic indices, when combined with Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, improved overall outcome prediction (P < 0.0001) achieving almost 90% accuracy. When all lactate measures in the first 24 hours were considered, the combination of LAC_TW24 and LAC_Δ24 significantly outperformed (P < 0.0001) static indices of lactate concentration, such as admission lactate, maximum lactate and minimum lactate.

Conclusions

In the first 24 hours following ICU admission, dynamic indices of hyperlactatemia have significant independent predictive value, improve the performance of illness severity score-based outcome predictions and are superior to simple static indices of lactate concentration.

【 授权许可】

   
2011 Nichol et al.; licensee BioMed Central Ltd.

【 图 表 】

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【 参考文献 】

• [1]Husain FA, Martin MJ, Mullenix PS, Steele SR, Elliott DC: Serum lactate and base deficit as predictors of mortality and morbidity. Am J Surg 2003, 185:485-491.
• [2]Suistomaa M, Ruokonen E, Kari A, Takala J: Time-pattern of lactate and lactate to pyruvate ratio in the first 24 hours of intensive care emergency admissions. Shock 2000, 14:8-12.
• [3]Khosravani H, Shahpori R, Stelfox HT, Kirkpatrick AW, Laupland KB: Occurrence and adverse effect on outcome of hyperlactatemia in the critically ill. Crit Care 2009, 13:R90. BioMed Central Full Text
• [4]Nichol AD, Egi M, Pettila V, Bellomo R, French C, Hart G, Davies A, Stachowski E, Reade MC, Bailey M, Cooper DJ: Relative hyperlactatemia and hospital mortality in critically ill patients: a retrospective multi-centre study. Crit Care 2010, 14:R25. BioMed Central Full Text
• [5]Meregalli A, Oliveira RP, Friedman G: Occult hypoperfusion is associated with increased mortality in hemodynamically stable, high-risk, surgical patients. Crit Care 2004, 8:R60-65. BioMed Central Full Text
• [6]Bakker J, Gris P, Coffernils M, Kahn RJ, Vincent JL: Serial blood lactate levels can predict the development of multiple organ failure following septic shock. Am J Surg 1996, 171:221-226.
• [7]Weil MH, Afifi AA: Experimental and clinical studies on lactate and pyruvate as indicators of the severity of acute circulatory failure (shock). Circulation 1970, 41:989-1001.
• [8]Mikkelsen ME, Miltiades AN, Gaieski DF, Goyal M, Fuchs BD, Shah CV, Bellamy SL, Christie JD: Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock. Crit Care Med 2009, 37:1670-1677.
• [9]De Backer D: Lactic acidosis. Intensive Care Med 2003, 29:699-702.
• [10]Manikis P, Jankowski S, Zhang H, Kahn RJ, Vincent JL: Correlation of serial blood lactate levels to organ failure and mortality after trauma. Am J Emerg Med 1995, 13:619-622.
• [11]Fall PJ, Szerlip HM: Lactic acidosis: from sour milk to septic shock. J Intensive Care Med 2005, 20:255-271.
• [12]Kaplan LJ, Kellum JA: Initial pH, base deficit, lactate, anion gap, strong ion difference, and strong ion gap predict outcome from major vascular injury. Crit Care Med 2004, 32:1120-1124.
• [13]McNelis J, Marini CP, Jurkiewicz A, Szomstein S, Simms HH, Ritter G, Nathan IM: Prolonged lactate clearance is associated with increased mortality in the surgical intensive care unit. Am J Surg 2001, 182:481-485.
• [14]Nguyen HB, Rivers EP, Knoblich BP, Jacobsen G, Muzzin A, Ressler JA, Tomlanovich MC: Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med 2004, 32:1637-1642.
• [15]Noritomi DT, Soriano FG, Kellum JA, Cappi SB, Biselli PJ, Libório AB, Park M: Metabolic acidosis in patients with severe sepsis and septic shock: a longitudinal quantitative study. Crit Care Med 2009, 37:2733-2739.
• [16]Friedman G, Berlot G, Kahn RJ, Vincent JL: Combined measurements of blood lactate concentrations and gastric intramucosal pH in patients with severe sepsis. Crit Care Med 1995, 23:1184-1193.
• [17]Jansen TC, van Bommel J, Schoonderbeek FJ, Sleeswijk Visser SJ, van der Klooster JM, Lima AP, Willemsen SP, Bakker J, LACTATE study group: Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial. Am J Respir Crit Care Med 2010, 182:752-761.
• [18]Knaus WA, Draper EA, Wagner DP, Zimmerman JE: APACHE II: a severity of disease classification system. Crit Care Med 1985, 13:818-829.
• [19]ANZICS: Modified APACHE III Admission Diagnosis [http://www.anzics.com.au] webcite
• [20]National Association of Testing Authorities [http://www.nata.asn.au] webcite
• [21]RCPA manual In The Royal College of Pathologists of Australasia. Fifth edition. Sydney: The Royal College of Pathologists of Australasia; 2009.
• [22]Finney SJ, Zekveld C, Elia A, Evans TW: Glucose control and mortality in critically ill patients. JAMA 2003, 290:2041-2047.
• [23]Tukey J: Exploratory Data Analysis. Reading, MA: Addison-Wesley; 1977.
• [24]Levy B, Sadoune LO, Gelot AM, Bollaert PE, Nabet P, Larcan A: Evolution of lactate/pyruvate and arterial ketone body ratios in the early course of catecholamine-treated septic shock. Crit Care Med 2000, 28:114-119.
• [25]Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M, Early Goal-Directed Therapy Collaborative Group: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001, 345:1368-1377.
• [26]Yang CS, Qiu HB, Huang YZ, Xie JF, Mo M, Liu SQ, Yang Y: [Prospective research on the prognosis of septic shock based on the change of lactate concentration in arterial blood]. Zhonghua Wai Ke Za Zhi 2009, 47:685-688.
• [27]Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA: Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA 2010, 303:739-746.
• [28]Myburgh JA, Higgins A, Jovanovska A, Lipman J, Ramakrishnan N, Santamaria J, CAT Study investigators: A comparison of epinephrine and norepinephrine in critically ill patients. Intensive Care Med 2008, 34:2226-2234.
• [29]Chang CT, Chen YC, Fang JT, Huang CC: Metformin-associated lactic acidosis: case reports and literature review. J Nephrol 2002, 15:398-402.
• [30]Falco V, Crespo M, Ribera E: Lactic acidosis related to nucleoside therapy in HIV-infected patients. Expert Opin Pharmacother 2003, 4:1321-1329.
• [31]Cole L, Bellomo R, Baldwin I, Hayhoe M, Ronco C: The impact of lactate-buffered high-volume hemofiltration on acid-base balance. Intensive Care Med 2003, 29:1113-1120.