Lactate Clearance Predicts Survival Among Patients in the Emergency Department with Severe Sepsis

Sundeep R Bhat, Kai E Swenson, Melissa W Francis, Charles R Wira, Sundeep R Bhat, Kai E Swenson, Melissa W Francis, Charles R Wira

Abstract

Introduction: Lactate clearance has been implicated as a predictor of mortality among emergency department (ED) patients with severe sepsis or septic shock. We aimed to validate prior studies showing that lactate clearance during the ED stay is associated with decreased mortality.

Methods: Retrospective dual-centered cross-sectional study using patients identified in the Yale-New Haven Hospital Emergency Medicine sepsis registry with severe sepsis or septic shock who had initial lactate levels measured in the ED and upon arrival (<24 hours) to the hospital floor. Lactate clearance was calculated as percent of serum lactate change from ED to floor measurement. We compared mortality and hospital interventions between patients who cleared lactate and those who did not.

Results: 207 patients (110 male; 63.17±17.9 years) were included. Two reviewers extracted data with 95% agreement. One hundred thirty-six patients (65.7%) had severe sepsis and 71 patients (34.3%) had septic shock. There were 171 patients in the clearance group and 36 patients in the non-clearance group. The 28-day mortality rates were 15.2% in the lactate clearance group and 36.1% in the non-clearance group (p<0.01). Vasopressor support was initiated more often in the non-clearance group (61.1%) than in the clearance group (36.8%, p<0.01) and mechanical ventilation was used in 66.7% of the non-clearance group and 36.3% of the clearance group (p=0.001).

Conclusion: Patients who do not clear their lactate in the ED have significantly higher mortality than those with decreasing lactate levels. Our results are confirmatory of other literature supporting that lactate clearance may be used to stratify mortality-risk among patients with severe sepsis or septic shock.

Figures

Figure 1
Figure 1
Hospital interventions for clearance and non-clearance groups. A significantly higher ratio of patients in the non-clearance group required vasopressor support within 72 hours of admission compared with the rate of vasopressor use in the clearance group (p

Figure 2

Mortality rates by lactate clearance…

Figure 2

Mortality rates by lactate clearance group. 28-day in-hospital mortality rates were significantly lower…

Figure 2
Mortality rates by lactate clearance group. 28-day in-hospital mortality rates were significantly lower among patients who cleared lactate (15.2% mortality) compared with those who did not (36.1% mortality, p
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    1. Wang HE, Shapiro NI, Angus DC, et al. National estimates of severe sepsis in United States emergency departments. Crit Care Med. 2007;35(8):1928–1936. - PubMed
    1. Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29(7):1303–1310. - PubMed
    1. Martin GS, Mannino DM, Eaton S, et al. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med. 2003;348(16):1546–1554. - PubMed
    1. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368–1377. - PubMed
    1. Otero RM, Nguyen HB, Huang DT, et al. Early goal-directed therapy in severe sepsis and septic shock revisited: concepts, controversies, and contemporary findings. Chest. 2006;130(5):1579–1595. - PubMed
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Figure 2
Figure 2
Mortality rates by lactate clearance group. 28-day in-hospital mortality rates were significantly lower among patients who cleared lactate (15.2% mortality) compared with those who did not (36.1% mortality, p

References

    1. Wang HE, Shapiro NI, Angus DC, et al. National estimates of severe sepsis in United States emergency departments. Crit Care Med. 2007;35(8):1928–1936.
    1. Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29(7):1303–1310.
    1. Martin GS, Mannino DM, Eaton S, et al. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med. 2003;348(16):1546–1554.
    1. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368–1377.
    1. Otero RM, Nguyen HB, Huang DT, et al. Early goal-directed therapy in severe sepsis and septic shock revisited: concepts, controversies, and contemporary findings. Chest. 2006;130(5):1579–1595.
    1. Jones AE, Focht A, Horton JM, et al. Prospective external validation of the clinical effectiveness of an emergency department-based early goal-directed therapy protocol for severe sepsis and septic shock. Chest. 2007;132(2):425–432.
    1. Bohnen JM, Mustard RA, Oxholm SE, et al. APACHE II score and abdominal sepsis. A prospective study. Arch Surg. 1988;123(2):225–229.
    1. Knaus WA, Draper EA, Wagner DP, et al. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13(10):818–829.
    1. Nguyen HB, Banta JE, Cho TW, et al. Mortality predictions using current physiologic scoring systems in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle. Shock. 2008;30(1):23–28.
    1. Shapiro NI, Howell MD, Talmor D, et al. Mortality in Emergency Department Sepsis (MEDS) score predicts 1-year mortality. Crit Care Med. 2007;35(1):192–198.
    1. Shapiro NI, Wolfe RE, Moore RB, et al. Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule. Crit Care Med. 2003;31(3):670–675.
    1. Afessa B, Gajic O, Keegan MT. Severity of illness and organ failure assessment in adult intensive care units. Crit Care Clin. 2007;23(3):639–658.
    1. Ferreira FL, Bota DP, Bross A, et al. Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA. 2001;286(14):1754–1758.
    1. Peres Bota D, Melot C, Lopes Ferreira F, et al. The Multiple Organ Dysfunction Score (MODS) versus the Sequential Organ Failure Assessment (SOFA) score in outcome prediction. Intensive Care Med. 2002;28(11):1619–1624.
    1. Bakker J, Gris P, Coffernils M, et al. Serial blood lactate levels can predict the development of multiple organ failure following septic shock. Am J Surg. 1996;171(2):221–226.
    1. Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992;101(6):1644–1655.
    1. Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003;31(4):1250–1256.
    1. Nguyen HB, Rivers EP, Knoblich BP, et al. Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med. 2004;32(8):1637–1642.
    1. Shapiro NI, Howell MD, Talmor D, et al. Serum lactate as a predictor of mortality in emergency department patients with infection. Ann Emerg Med. 2005;45(5):524–528.
    1. Trzeciak S, Dellinger RP, Chansky ME, et al. Serum lactate as a predictor of mortality in patients with infection. Intensive Care Med. 2007;33(6):970–977.
    1. Bakker J, Jansen TC. Don’t take vitals, take a lactate. Intensive Care Med. 2007;33(11):1863–1865.
    1. Aduen J, Bernstein WK, Khastgir T, et al. The use and clinical importance of a substrate-specific electrode for rapid determination of blood lactate concentrations. JAMA. 1994;272(21):1678–1685.
    1. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008;36(1):296–327.
    1. Donnino MW, Nguyen B, Jacobsen G, et al. Cryptic Septic Shock: A Sub-analysis of Early, Goal-Directed Therapy. Paper presented at: CHEST 2003-Slide Presentations; October 27, 2003; 2003.
    1. Arnold RC, Shapiro NI, Jones AE, et al. Multicenter study of early lactate clearance as a determinant of survival in patients with presumed sepsis. Shock. 2009;32(1):35–39.
    1. Jones AE, Shapiro NI, Trzeciak S, et al. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010;303(8):739–746.
    1. Daniels R, Nutbeam T, McNamara G, et al. The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study. Emerg Med J. 2011;28(6):507–12.
    1. Nguyen HB, Corbett SW, Steele R, et al. Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality. Crit Care Med. 2007;35(4):1105–1112.
    1. Girardis M, Rinaldi L, Donno L, et al. Effects on management and outcome of severe sepsis and septic shock patients admitted to the intensive care unit after implementation of a sepsis program: a pilot study. Crit Care. 2009;13(5):R143.
    1. Lu NF, Zheng RQ, Lin H, et al. Improved sepsis bundles in the treatment of septic shock: a prospective clinical study. Am J Emerg Med. 2015;33:1045–49.
    1. Zhang L, Zhu G, Han L, et al. Early goal-directed therapy in the management of severe sepsis or septic shock in adults: a meta-analysis of randomized controlled trials. BMC Medicine. 2015;13:71.
    1. Liu V, Morehouse JW, Soule J, et al. Fluid volume, lactate values, and mortality in sepsis patients with intermediate lactate values. Ann Am Thorac Soc. 2013;10(5):466–73.
    1. Abramson D, Scalea TM, Hitchcock R, et al. Lactate clearance and survival following injury. J Trauma. 1993;35(4):584–588. discussion 588–589.
    1. Blow O, Magliore L, Claridge JA, et al. The golden hour and the silver day: detection and correction of occult hypoperfusion within 24 hours improves outcome from major trauma. J Trauma. 1999;47(5):964–969.
    1. Donnino MW, Miller J, Goyal N, et al. Effective lactate clearance is associated with improved outcome in post-cardiac arrest patients. Resuscitation. 2007;75(2):229–234.
    1. Vincent JL, Dufaye P, Berre J, et al. Serial lactate determinations during circulatory shock. Crit Care Med. 1983;11(6):449–451.
    1. Scott S, Antonaglia V, Guiotto G, et al. Two-hour lactate clearance predicts negative outcome in patients with cardiorespiratory insufficiency. Crit Care Res Pract. 2010;917053
    1. Billeter A, Turina M, Seifert B, et al. Early Serum Procalcitonin, Interleukin-6, and 24-Hour Lactate Clearance: Useful Indicators of Septic Infections in Severely Traumatized Patients. World J Surg. 2009
    1. Vincent JL. Serial blood lactate levels reflect both lactate production and clearance. Crit Care Med. 2015;43(6):e209.

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