Nikhil Jagan1, Lee E Morrow2,3, Ryan W Walters4, Robert W Plambeck2, Tej M Patel5, Douglas R Moore2, Mark A Malesker6. 1. Division of Pulmonary & Critical Care, Creighton University School of Medicine, 7710 Mercy Road, Suite 410, Omaha, NE, 68124, USA. nikhiljagan@creighton.edu. 2. Division of Pulmonary & Critical Care, Creighton University School of Medicine, 7710 Mercy Road, Suite 410, Omaha, NE, 68124, USA. 3. VA Nebraska-Western Iowa, Section of Pulmonary and Critical Care, Omaha, USA. 4. Division of Clinical Research & Evaluative Sciences, Creighton University School of Medicine, Omaha, USA. 5. Department of Internal Medicine, Washington University School of Medicine, St. Louis, USA. 6. Creighton University School of Pharmacy and Health Professions, Omaha, USA.
Abstract
BACKGROUND: Diametrically opposed positions exist regarding the deleterious effects of elevated lactate. There are data suggesting that it is a detrimental proxy for tissue hypoperfusion and anaerobic metabolism in sepsis and an alternative viewpoint is that some of the hyperlactatemia produced maybe adaptive. This study was conducted to explore the relationship between serum lactate levels, mean arterial blood pressure (MAP), and sympathetic stimulation in patients with sepsis. METHODS: Retrospective analysis of prospectively collected clinical data from four community-based hospitals and one academic medical center. 8173 adults were included. Heart rate (HR) was used as a surrogate marker of sympathetic stimulation. HR, MAP, and lactate levels were measured upon presentation. RESULTS: MAP and HR interacted to affect lactate levels with the highest levels observed in patients with low MAP and high HR (3.6 mmol/L) and the lowest in patients with high MAP and low HR (2.2 mmol/L). The overall mortality rate was 12.4%. Each 10 beats/min increase in HR increased the odds of death 6.0% (95% CI 2.6% to 9.4%), each 1 mmol/L increase in lactate increased the odds of death 20.8% (95% CI 17.4% to 24.2%), whereas each 10 mmHg increase in MAP reduced the odds of death 12.3% (95% CI 9.2% to 15.4%). However, HR did not moderate or mediate the association between lactate and death. CONCLUSIONS: In septic patients, lactate production was associated with increased sympathetic activity (HR ≥ 90) and hypotension (MAP < 65 mmHg) and was a significant predictor of mortality. Because HR, lactate, and MAP were associated with mortality, our data support the present strategy of using these measurements to gauge severity of illness upon presentation. Since HR did not moderate or mediate the association between lactate and death, criticisms alleging that lactate caused by sympathetic stimulation is adaptive (i.e., less harmful) do not appear substantiated.
BACKGROUND: Diametrically opposed positions exist regarding the deleterious effects of elevated lactate. There are data suggesting that it is a detrimental proxy for tissue hypoperfusion and anaerobic metabolism in sepsis and an alternative viewpoint is that some of the hyperlactatemia produced maybe adaptive. This study was conducted to explore the relationship between serum lactate levels, mean arterial blood pressure (MAP), and sympathetic stimulation in patients with sepsis. METHODS: Retrospective analysis of prospectively collected clinical data from four community-based hospitals and one academic medical center. 8173 adults were included. Heart rate (HR) was used as a surrogate marker of sympathetic stimulation. HR, MAP, and lactate levels were measured upon presentation. RESULTS: MAP and HR interacted to affect lactate levels with the highest levels observed in patients with low MAP and high HR (3.6 mmol/L) and the lowest in patients with high MAP and low HR (2.2 mmol/L). The overall mortality rate was 12.4%. Each 10 beats/min increase in HR increased the odds of death 6.0% (95% CI 2.6% to 9.4%), each 1 mmol/L increase in lactate increased the odds of death 20.8% (95% CI 17.4% to 24.2%), whereas each 10 mmHg increase in MAP reduced the odds of death 12.3% (95% CI 9.2% to 15.4%). However, HR did not moderate or mediate the association between lactate and death. CONCLUSIONS: In septic patients, lactate production was associated with increased sympathetic activity (HR ≥ 90) and hypotension (MAP < 65 mmHg) and was a significant predictor of mortality. Because HR, lactate, and MAP were associated with mortality, our data support the present strategy of using these measurements to gauge severity of illness upon presentation. Since HR did not moderate or mediate the association between lactate and death, criticisms alleging that lactate caused by sympathetic stimulation is adaptive (i.e., less harmful) do not appear substantiated.
Entities:
Keywords:
Critical care outcomes; Lactic acid; Prognosis; Resuscitation; Sepsis; Shock
Authors: Daniel De Backer; Jacques Creteur; Jean-Charles Preiser; Marc-Jacques Dubois; Jean-Louis Vincent Journal: Am J Respir Crit Care Med Date: 2002-07-01 Impact factor: 21.405
Authors: Craig M Coopersmith; Daniel De Backer; Clifford S Deutschman; Ricard Ferrer; Ishaq Lat; Flavia R Machado; Greg S Martin; Ignacio Martin-Loeches; Mark E Nunnally; Massimo Antonelli; Laura E Evans; Judith Hellman; Sameer Jog; Jozef Kesecioglu; Mitchell M Levy; Andrew Rhodes Journal: Crit Care Med Date: 2018-08 Impact factor: 7.598
Authors: Vincent Liu; Gabriel J Escobar; John D Greene; Jay Soule; Alan Whippy; Derek C Angus; Theodore J Iwashyna Journal: JAMA Date: 2014-07-02 Impact factor: 56.272
Authors: Glenn Hernández; Gustavo A Ospina-Tascón; Lucas Petri Damiani; Elisa Estenssoro; Arnaldo Dubin; Javier Hurtado; Gilberto Friedman; Ricardo Castro; Leyla Alegría; Jean-Louis Teboul; Maurizio Cecconi; Giorgio Ferri; Manuel Jibaja; Ronald Pairumani; Paula Fernández; Diego Barahona; Vladimir Granda-Luna; Alexandre Biasi Cavalcanti; Jan Bakker; Glenn Hernández; Gustavo Ospina-Tascón; Lucas Petri Damiani; Elisa Estenssoro; Arnaldo Dubin; Javier Hurtado; Gilberto Friedman; Ricardo Castro; Leyla Alegría; Jean-Louis Teboul; Maurizio Cecconi; Maurizio Cecconi; Giorgio Ferri; Manuel Jibaja; Ronald Pairumani; Paula Fernández; Diego Barahona; Alexandre Biasi Cavalcanti; Jan Bakker; Glenn Hernández; Leyla Alegría; Giorgio Ferri; Nicolás Rodriguez; Patricia Holger; Natalia Soto; Mario Pozo; Jan Bakker; Deborah Cook; Jean-Louis Vincent; Andrew Rhodes; Bryan P Kavanagh; Phil Dellinger; Wim Rietdijk; David Carpio; Nicolás Pavéz; Elizabeth Henriquez; Sebastian Bravo; Emilio Daniel Valenzuela; Magdalena Vera; Jorge Dreyse; Vanessa Oviedo; Maria Alicia Cid; Macarena Larroulet; Edward Petruska; Claudio Sarabia; David Gallardo; Juan Eduardo Sanchez; Hugo González; José Miguel Arancibia; Alex Muñoz; Germán Ramirez; Florencia Aravena; Andrés Aquevedo; Fabián Zambrano; Milan Bozinovic; Felipe Valle; Manuel Ramirez; Victor Rossel; Pilar Muñoz; Carolina Ceballos; Christian Esveile; Cristian Carmona; Eva Candia; Daniela Mendoza; Aída Sanchez; Daniela Ponce; Daniela Ponce; Jaime Lastra; Bárbara Nahuelpán; Fabrizio Fasce; Cecilia Luengo; Nicolas Medel; Cesar Cortés; Luz Campassi; Paolo Rubatto; Nahime Horna; Mariano Furche; Juan Carlos Pendino; Lisandro Bettini; Carlos Lovesio; María Cecilia González; Jésica Rodruguez; Héctor Canales; Francisco Caminos; Cayetano Galletti; Estefanía Minoldo; Maria Jose Aramburu; Daniela Olmos; Nicolás Nin; Jordán Tenzi; Carlos Quiroga; Pablo Lacuesta; Agustín Gaudín; Richard Pais; Ana Silvestre; Germán Olivera; Gloria Rieppi; Dolores Berrutti; Marcelo Ochoa; Paul Cobos; Fernando Vintimilla; Vanessa Ramirez; Milton Tobar; Fernanda García; Fabricio Picoita; Nelson Remache; Vladimir Granda; Fernando Paredes; Eduardo Barzallo; Paul Garcés; Fausto Guerrero; Santiago Salazar; German Torres; Cristian Tana; José Calahorrano; Freddy Solis; Pedro Torres; Luís Herrera; Antonio Ornes; Verónica Peréz; Glenda Delgado; Alexei López; Eliana Espinosa; José Moreira; Blanca Salcedo; Ivonne Villacres; Jhonny Suing; Marco Lopez; Luis Gomez; Guillermo Toctaquiza; Mario Cadena Zapata; Milton Alonso Orazabal; Ruben Pardo Espejo; Jorge Jimenez; Alexander Calderón; Gustavo Paredes; José Luis Barberán; Tatiana Moya; Horacio Atehortua; Rodolfo Sabogal; Guillermo Ortiz; Antonio Lara; Fabio Sanchez; Alvaro Hernán Portilla; Humberto Dávila; Jorge Antonio Mora; Luis Eduardo Calderón; Ingrid Alvarez; Elena Escobar; Alejandro Bejarano; Luis Alfonso Bustamante; José Luis Aldana Journal: JAMA Date: 2019-02-19 Impact factor: 56.272
Authors: Mark E Mikkelsen; Andrea N Miltiades; David F Gaieski; Munish Goyal; Barry D Fuchs; Chirag V Shah; Scarlett L Bellamy; Jason D Christie Journal: Crit Care Med Date: 2009-05 Impact factor: 7.598