Lactate Testing in Suspected Sepsis

Abstract

Objectives Serum lactate monitoring is central to risk stratification and management of sepsis and is now part of a potential quality measure. We examined 11-year trends in lactate testing and predictors of failure to measure lactates in patients with severe sepsis. Design Retrospective cohort study. Setting Two U.S. academic hospitals. Patients Adult patients admitted from 2003–2013. Interventions Annual rates of lactate measurement were assessed in patients who had blood cultures ordered and patients with severe sepsis, as defined by concomitant ICD-9 codes for infection and organ dysfunction. The approximate time of suspected sepsis was determined by the first blood culture order with concurrent antibiotic initiation. Multivariate analysis was performed to identify predictors of failure to measure lactates in severe sepsis cases in 2013. Measurements and Results Among hospitalizations with blood culture orders, rates of lactate measurement increased from 11% in 2003 to 48% in 2013 (p<0.001 for linear trend). Rates of repeat lactate measurement within 6 hours after lactate levels ≥ 4.0 mmol/L increased from 23% to 69% (p<0.001). Patients were progressively less likely to be on vasopressors at the time of first lactate measurement (49% in 2003 vs 21% in 2013, p<0.001). Despite these trends, lactates were measured at the time of suspected sepsis in only 65% of patients with severe sepsis in 2013. On multivariate analysis, hospital-onset of sepsis and hospitalization on a nonmedical service were significant predictors of failure to measure lactates (adjusted ORs 7.56, 95% CI 6.31–9.06 and 2.08, 95% CI 1.76–2.24, respectively). Conclusions Lactate testing has increased dramatically over time and is being extended to patients without overt shock. However, rates of serial lactate testing are still suboptimal and lactates are not being measured in many patients with severe sepsis. Hospital-onset sepsis and nonmedical units may be high-yield targets for quality improvement initiatives.

Objective Sepsis Surveillance Using Electronic Clinical Data

“…This is likely due to the increasing use of lactate testing over time and extension to patients without evidence of other organ dysfunction. 16 This may reflect the impact of the Surviving Sepsis Campaign guidelines and numerous publications suggesting that measuring lactate levels is beneficial. 12,25–28 Our findings suggest that although lactate measurement may be important for the clinical care of individual patients, it is less suited to helping estimate changes in population-level sepsis burden over time because of significant increases in testing rates.…”

“…13–16 We performed a sensitivity analysis, however, to assess whether and how the inclusion of lactate (with a level ≥2.0mmol/L) would affect the perceived incidence of severe sepsis over time. We also explored the utility of a parsimonious “simplified surveillance definition” that required only evidence of suspected infection and vasopressors, initiation of mechanical ventilation for at least 2 days, or an acute rise in creatinine—reflecting the most common forms of organ dysfunction associated with sepsis.…”

Time to Lactate Measurement Affects Efficacy of Initial Lactate on Mortality in critically ill patients with sepsis.

“…Based on the International Guidelines for Management of Sepsis and Septic Shock in 2016, a revised "1-hour bundle" was recently developed with the combination of the 3-hour and 6-hour bundles for the purpose of immediately beginning resuscitation and management [20,7]. Lactate measurement, which is an important component of a sepsis bundle, has increased dramatically since 2003 and is performed on patients without overt shock [10]. Current evidence indicates the necessity of early lactate measurement in patients with initial intermediate or elevated lactate levels [21][22][23]8,24].…”

“…Lactate measurement is an important component of the early management of sepsis, and its optimal execution time is the focus of the current study. Current evidence indicates that delays in the detection time of lactate will lead to an increase in poor prognosis, including death [8][9][10][11]. However, whether the delay of lactate measurement will affect the e cacy of initial lactate on mortality has always been neglected.…”

Effects of Hyperglycemia on Adults Hospitalized With Sepsis

“…On multivariate analysis, hospital-onset sepsis and hospitalization on a nonmedical service were common predictors for failure to measure lactates (adjusted odds ratio, 7.56; 95% CI [6.31-9.06] and adjusted odds ratio, 2.08; 95% CI [1.76-2.24], respectively). The researchers found hospital-onset sepsis and nonmedical units are still suboptimal in measuring serial lactate levels in septic adults despite SSC guidelines (Rhee, Murphy, Platt & Klompas, 2015).…”