The Impact of Serial Lactate Monitoring on Emergency Department Resuscitation Interventions and Clinical Outcomes in Severe Sepsis and Septic Shock

Abstract

Monitoring in the setting of critical illness must be linked to beneficial therapy in order to affect clinical outcome. Elevated serum lactate is associated with an increase in mortality in Emergency Department (ED) patients with severe sepsis and septic shock. The reduction of lactate levels towards normal during acute resuscitation is associated with improved clinical outcomes. The majority of data demonstrating the interventions used to achieve a reduction in lactate levels, and the associated clinical outcomes, have been obtained during protocolized randomized trials. We therefore conducted a retrospective observational cohort study of 243 adult patients with severe sepsis and septic shock to assess the interventions associated with non-protocolized serial lactate monitoring, and to assess clinical outcomes. A multivariable model was used to assess outcome differences between the serial lactate (SL) and no serial lactate (NL) cohorts. The SL group received more crystalloid resuscitation (3.6 vs. 2.5 liters, p<0.01) central venous oxygen saturation monitoring (30% vs. 12%, p<0.01), and central venous pressure monitoring (23.5% vs. 11.8%, p=0.02). By day 28, a total of 31 patients in the SL group (23.5%) and 44 in the NL group (39.6%) had died. Multivariable logistic regression analysis demonstrated that the lack of serial lactate monitoring was independently associated with mortality (adjusted OR 2.09; 95% confidence interval [CI], 1.12 to 3.89; p=0.02). The SL group also showed greater improvement in 24 hour SOFA scores (1.16 vs. 0.19, p=0.03), decreased intensive care unit length of stay in days (4.6 vs 6.0, p=0.04), more ventilator-free (19.9 vs. 16, p=0.05) and vasopressor-free (21.6 vs. 17.9 p=0.02) days. In the setting of routine clinical care, serial lactate monitoring is associated with an increase in crystalloid administration, resuscitation interventions, and improved clinical outcomes in ED patients with severe sepsis and septic shock. This suggests that serial lactate monitoring, targeting a reduction in lactate levels to normal, is a generalizable resuscitation target in the ED.

Lactic acidosis, hyperlactatemia and sepsis

“…28 Similarly, other Authors found that using lactate-guided therapy compared with control and found a significant reduction in hospital mortality. 29 supporting the concept that a decrease in elevated lactate concentrations might reflect successful management. In human medicine the speed at which hyperlactatemia resolves with appropriate therapy may be considered a useful prognostic indicator in critically ill, even if lactate alone should not be considered sufficient to judge success or failure of treatment.…”

Sepsis-associated pulmonary complications in emergency department patients monitored with serial lactate: An observational cohort study

“…In a previous investigation, serial lactate monitoring in patients with severe sepsis and septic shock was associated with improved mortality outside the setting of a randomized trial[19]. The use of serial lactate monitoring seemed to be a surrogate for a “more aggressive” acute resuscitation, as there was a greater use of central venous catheters, as well as monitoring of central venous pressure and mixed venous oxygenation.…”

“…This was a retrospective observational cohort study and preplanned secondary analysis of previously published data, reported in accordance with The Strengthening the Reporting of Observational Studies in Epidemiology Statement: Guidelines for Reporting Observational Studies [19,20]. This study was approved by the Human Research Protection Office at the principal investigator’s institution with waiver of informed consent, approval number 201206130.…”

“…In the setting of sepsis, evidence of hypoperfusion (elevated lactate level) has also been directly associated with ARDS progression in ED patients[15]. Lactate clearance is associated with improved outcome in critically ill patients, and serial lactate monitoring has been shown to be a strategy associated with improved outcomes[16–19]. These data provide rationale for serial lactate monitoring as a possible therapeutic target for ARDS prevention[19].…”

“…Lactate clearance is associated with improved outcome in critically ill patients, and serial lactate monitoring has been shown to be a strategy associated with improved outcomes[16–19]. These data provide rationale for serial lactate monitoring as a possible therapeutic target for ARDS prevention[19]. However, the impact of serial lactate monitoring on the incidence of ARDS has not been investigated.…”