Fluid Volume, Lactate Values, and Mortality in Sepsis Patients with Intermediate Lactate Values

Abstract

Rationale: Patients with severe sepsis without shock or tissue hypoperfusion face substantial mortality; however, treatment guidelines are lacking. Hospital and 30-day mortality were 8.2 and 13.3%, respectively, for patients with lactate clearance; they were 18.7 and 24.7%, respectively, for those without lactate clearance. Each 10% increase in repeat lactate values was associated with a 9.4% (95% confidence interval [CI] = 7.8-11.1%) increase in the odds of hospital death. Within 4 hours, patients received 32 (618) ml/kg of fluid. Each 7.5 ml/kg increase was associated with a 1.3% (95% CI = 0.6-2.1%) decrease in repeat lactate. Across an unrestricted range, increased fluid was not associated with improved mortality. However, when limited to less than 45 ml/kg, additional fluid was associated with a trend toward improved survival (odds ratio = 0.92; 95% CI = 0.82-1.03) that was statistically significant among patients with highly concordant fluid records.Conclusions: Early fluid administration, below 45 ml/kg, was associated with modest improvements in lactate clearance and potential improvements in mortality. Further study is needed to define treatment strategies in this prevalent and morbid group of patients with sepsis.

Multicenter Implementation of a Treatment Bundle for Patients with Sepsis and Intermediate Lactate Values

“…Such patients have lower mortality rates than those with septic shock; however, their hospital and 30-day mortality rates were substantially (15). Because most of these patients are treated outside critical care settings, they are also less likely to receive standardized care approaches (12,14). As a result, we sought to implement a standardized treatment strategy that incorporated the principles of effective sepsis care defined in prior studies.…”

“…(2) an initial lactate value greater than or equal to 2 mmol/L and less than 4 mmol/L, and (3) antibiotics that were administered in the ED and also within 12 hours of ED arrival. From among this initial population, we excluded patients who met EGDT eligibility criteria during their ED stay on the basis of manually validated data prospectively collected by local quality improvement staff using regional standards and Internet-based data tools (12).…”

“…We determined compliance with bundle elements on the basis of previously established methods for analyzing electronic medical record data (12). For antibiotic measures, we captured all enteral and intravenous antibiotics and calculated the elapsed time from ED entry and time 0 to administration time.…”

“…In contrast, few studies have been focused on assessing optimal treatment strategies for patients with patients with less severe sepsis, including so-called intermediate lactate patients who have normal blood pressure and lactate values between 2 and 4 mmol/L (12)(13)(14)(15)(16). Such patients also face substantial hospital mortality and are often treated in less standardized, non-ICU hospital settings (12).…”

“…Such patients also face substantial hospital mortality and are often treated in less standardized, non-ICU hospital settings (12). Because patients with intermediate lactate values are also more common in hospitalized populations, they contribute to a number of overall hospital deaths nearly equivalent to that of patients with more severe sepsis (1).…”