The prognostic value of blood lactate levels relative to that of vital signs in the pre-hospital setting: a pilot study

Tim C Jansen, Jasper van Bommel, Paul G Mulder, Johannes H Rommes, Selma J M Schieveld, Jan Bakker, Tim C Jansen, Jasper van Bommel, Paul G Mulder, Johannes H Rommes, Selma J M Schieveld, Jan Bakker

Abstract

Introduction: A limitation of pre-hospital monitoring is that vital signs often do not change until a patient is in a critical stage. Blood lactate levels are suggested as a more sensitive parameter to evaluate a patient's condition. The aim of this pilot study was to find presumptive evidence for a relation between pre-hospital lactate levels and in-hospital mortality, corrected for vital sign abnormalities.

Methods: In this prospective observational study (n = 124), patients who required urgent ambulance dispatching and had a systolic blood pressure below 100 mmHg, a respiratory rate less than 10 or more than 29 breaths/minute, or a Glasgow Coma Scale (GCS) below 14 were enrolled. Nurses from Emergency Medical Services measured capillary or venous lactate levels using a hand-held device on arrival at the scene (T1) and just before or on arrival at the emergency department (T2). The primary outcome measured was in-hospital mortality.

Results: The average (standard deviation) time from T1 to T2 was 27 (10) minutes. Non-survivors (n = 32, 26%) had significantly higher lactate levels than survivors at T1 (5.3 vs 3.7 mmol/L) and at T2 (5.4 vs 3.2 mmol/L). Mortality was significantly higher in patients with lactate levels of 3.5 mmol/L or higher compared with those with lactate levels below 3.5 mmol/L (T1: 41 vs 12% and T2: 47 vs 15%). Also in the absence of hypotension, mortality was higher in those with higher lactate levels. In a multivariable Cox proportional hazard analysis including systolic blood pressure, heart rate, GCS (all at T1) and delta lactate level (from T1 to T2), only delta lactate level (hazard ratio (HR) = 0.20, 95% confidence interval (CI) = 0.05 to 0.76, p = 0.018) and GCS (HR = 0.93, 95% CI = 0.88 to 0.99, p = 0.022) were significant independent predictors of in-hospital mortality.

Conclusions: In a cohort of patients that required urgent ambulance dispatching, pre-hospital blood lactate levels were associated with in-hospital mortality and provided prognostic information superior to that provided by the patient's vital signs. There is potential for early detection of occult shock and pre-hospital resuscitation guided by lactate measurement. However, external validation is required before widespread implementation of lactate measurement in the out-of-hospital setting.

Figures

Figure 1
Figure 1
Mean lactate levels in survivors (S) and non-survivors (NS) on arrival of the ambulance at the scene (T1) and just before or on arrival at the emergency department (T2). Arrow bar represents standard error. Number of patients at T1: n = 124 and at T2: n = 106.
Figure 2
Figure 2
Patient survival according to lactate levels below or above the cut-off threshold of 3.5 mmol/L.
Figure 3
Figure 3
In-hospital mortality stratified by systolic blood pressure and blood lactate level measured at arrival of the ambulance at the scene (T1). *p = 0.046 #p = 0.032 Number of patients per group: low systolic blood pressure (SBP)/low lactate n = 8, low SBP/high lactate n = 25, high SBP/low lactate n = 58, high SBP/high lactate n = 33.

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