Normal-Range Blood Lactate Concentration in Septic Shock Is Prognostic and Predictive

Abstract

We hypothesized that lactate levels even within the normal range are prognostic and that low lactate levels predict a beneficial response to vasopressin infusion in septic shock. We conducted a retrospective analysis using the Vasopressin in Septic Shock Trial (VASST) as a derivation cohort (n = 665), then validated using another single-center septic shock cohort, St Paul's Hospital (SPH) cohort (n = 469). Lactate levels were divided into quartiles. The primary outcome variable was 28-day mortality in both cohorts. We used receiver operating characteristic (ROC) curve analysis to compare the prognostic value of lactate concentrations versus Acute Physiology and Chronic Health Evaluation II scores. We then explored whether lactate concentrations might predict beneficial response to vasopressin compared with noradrenaline in VASST. Normal lactate range is less than 2.3 mmol/L. At enrollment, patients in the second quartile (1.4 < lactate < 2.3 mmol/L) had significantly increased mortality and organ dysfunction compared with patients who had lactate ≤ 1.4 mmol/L (quartile 1) (P < 0.0001). Quartile 2 outcomes were as severe as quartile 3 (2.3 ≤ lactate < 4.4 mmol/L) outcomes. Baseline lactate values (ar ea under the ROC curve = 0.63, 0.66; VASST, SPH) were as good as Acute Physiology and Chronic Health Evaluation II scores (area under the ROC curve = 0.66, 0.73; VASST, SPH) as prognostic indicators of 28-day mortality. Lactate concentrations of 1.4 mmol/L or less predicted a beneficial response in those randomized to vasopressin compared with noradrenaline in VASST (P < 0.05). Lactate concentrations within the "normal" range can be a useful prognostic indicator in septic shock. Furthermore, patients whose lactate level is less than or equal to 1.4 mmol/L may benefit from vasopressin infusion.

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

“…A handful of smaller studies evaluated patients with sepsis with intermediate lactate values and reported similar findings (15,16,18,(28)(29)(30). In our large, modern cohort, we confirm that rising index lactate values were associated with increased mortality.…”

“…In a cohort of 5,041 critically ill patients, Nichol and colleagues (35) found that the addition of dynamic lactate indices to existing severity measures dramatically improved outcomes prediction. In this context, the current study confirms a consistent relationship between lactate indices and mortality across a broad population of patients with sepsis that is stratified by, but independent of, shock or the need for critical care (16,28,30,35,37).…”

The Diagnosis and Hemodynamic Monitoring of Circulatory Shock: Current and Future Trends

“…The SV then is measured beat by beat, using a pulse contour analysis, through a thermistor tipped catheter inserted into a peripheral artery. The SV, CI, and CO measured by the two types of calibrated pulse contour technologies were shown to agree well with the values obtained with PAC [19][20]. Moreover, TPTD itself offers other critical volumetric parameters (GEDV, ITBV) and organ function parameters (EVLW, PVPi, and CPO).…”

“…The new ESICMc-2014 report underlines the fact that blood lactate levels > 2mEq/L should be considered the hallmark of an existing shock syndrome [2,20]. Also, previous trials showed that the concomitant presence of hemodynamic shock plus hyperlactatemia> 4.0 mmol/L is associated with a mortality of 30% to 45% [12.19].…”

Inhibition of the oxygen sensor PHD2 in the liver improves survival in lactic acidosis by activating the Cori cycle

“…Lactic acidosis is frequently associated with multiple organ failure, which has an extremely poor survival rate (18). Because the outcome of multiple organ failure treatment is closely correlated with blood lactate levels (19)(20)(21)(22), it is believed that reducing blood lactate levels would improve outcomes in this setting. To test whether pharmacological PHD2 inhibition could have a beneficial effect on such severe medical conditions, including endotoxin-induced shock, wild-type mice were treated with vehicle or the PHD inhibitor GSK360A by oral gavage immediately after the i.p.…”