Introduction. There are many discussions that one of the mortality risk markers for patients admitted to intensive care unit (ICU) with different etiology shock is admission blood lactate level. It is believed that serum lactate could be used as an early marker of mortality risk determination. We are not aware about research studies regarding admission serum lactate prognostic significance in patients with severe community acquired pneumonia (CAP) in first 24 hours after admission to ICU in Latvia.
Aim of the study.
1. To evaluate the prognostic significance of the first lactate level in patients with severe pneumonia. To compare the statistical data of different blood lactate levels (LAC1, LAC2, LAC3, LAC4, LACMAX, LACMIN).
2. To find admission lactate reference level which is attributed to significant increase of mortality.
3. To compare with other markers and scoring systems like: PCT (procalcitonin), CRP (C-reactive protein), CURB-65 (pneumonia severity score), APACHEII (Acute Physiology and Chronic Health Evaluation II).
Material and methods. This is a retrospective observational study in which data were collected on all patients admitted to ICUwith pneumonia and sepsis and/or septic shock in two major Hospitals of Republic of Latvia (Eastern Clinical university hospital and Pauls Stradins Clinical university hospital) with primary diagnosis of severe community acquired pneumonia (CAP). We compared the relationship between lactate values that were collected in 24 hour period after admission in ICU and ICU mortality.
Results. In this study we analyzed data from consecutive 73 patients with severe CAP and sepsis and/or septic shock and we observed statistically significant difference between the first lactate level (LAC1) in survivors (2.7 [1.9-3.2] (mmol/l) and non-survivors 4.9 [4.3-7.5] (mmol/l); p<0.001).According to data patients with LAC1<3.0 (mmol/l) mortality risk was 0%, patients with LAC1 3.0 - 4.0 (mmol/l) risk was 42.1%, while patients with LAC1>4.0 (mmol/l) mortality risk reached 89.7%. Lactate level measurements in first 24 hours after arrival into the ICU have had high ability to stratify non-survivor patients: LAC1 (0.96), LAC2 (0.98), LAC3 (0.97), LAC4 (0.92), (AUC). Incomparison with other prognostic markers sensitivity and specificity following results were obtained: CRP (0.59), PCT (0.98), APACHE II (0.98), CURB-65 (0.63).
Conclusions. Summarizing data on patients with severe pneumonia and sepsis and/or septic shock admission lactate in first 24 hours have significant independent predictive value. In first 24 hours after admission in ICU higher mortality were observed if LAC1 was >3 (mmol/l). Data proves for the patients with severe pneumonia LAC1 is having similar prognostic ability like APACHEII and PCT, and significantly better prognostic ability than CRP and CURB-65.
1. Bernardin, G., Pradier, C., Tiger, F., et al. Blood pressure and arterial lactate level are early indicators of shortterm survival in human septic shock// Intensive Care Medicine, 1996; 22:17-25
2. Berry, M. N. The liver and lactic acidosis// Proc. Royal Society of Medicine, 1967; 60: 1260-2
3. Bersten, A.D., Soni, N. Oh’s intensive care manual. -6th ed. - Philadelphia: Butterworth Heinemann Elsvier 2009. - Pp. 145.-147
4. Broder, G., Weil, M.H. Excess lactate: an index of reversibility of shock in human patients// Science, 1964; 143: 1457-9
5. Cady, L. D., Weil, M. W., Afifi, A. A., et al. Quantitation of severity of critical illness with special reference to blood lactate//Critical Care Medicine, 1973; 1:75-80
6. Chertoff, J., Chisum, M., Garcia, B., Lascano, J. Lactate kinetics in sepsis and septic shock: a review of the literature and rationale for further research// Journal of Intensive Care, 2015; 3:39
7. Dellinger, R. P., Levy, M. M., Rhodes, A., et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012// CriticalCare Medicine, 2013; 41: 580-595
8. Gillet, Y., Bertrand, I., Vanhems, P., et al. Association between Staphylococcus aureus strains carrying gene for Panton-Valentine leukocidin and highly lethal necrotising pneumonia in young immunocompetent patients//Lancet, 2002; 359: 753 - 759
9. Gunnerson, K.J., Saul, M., He, S. et al. Lactate versus nonlactate metabolic acidosis: a retrospective outcome evaluation of critically ill patients//Critical Care Medicine, 2006; 10(1): R22
10. Gutierrez, F., Masia, M., Rodriguez, J. C., et al. M. Epidemiology of community-acquired pneumonia in adult patients at the dawn of the 21st century: a prospective study on the Mediterranean coast of Spain. Clinical Microbiology and Infectology, 2005; 11: 788-800
11. Gutierrez, G., Wulf, M. E. Lactic acidosis in sepsis: another commentary// Critical Care Medicine, 2005; 33: 2420-2
12. Heper, Y., Akal, E. H., Mistik, R., et al. Evaluation of serum C-reactive protein, procalcitonin, tumor necrosis factor alpha, and interleukin-10 levels as diagnostic and prognostic parameters in patients with communityacquired sepsis, severe sepsis, and septic shock// European Journal ofClinical Microbiology and Infectious Diseases, 2006; 25:481-491
13. Jansen, T. C., Bommel, J., Schoonderbeek, J.,et al. Early Lactate-Guided Therapy in Intensive Care Unit Patients// American Journal of Respiratory and Critical Care Medicine, 2010; 182: 752-761
14. Jat, K. N., Jhamb, U., Gupta, V. K. Serum lactate levels as the predictorof outcome in pediatric septic shock// Indian Journalof Critical Care Medicine, 2011; 15: 102-7
15. Knaus, W. A., Draper, E. A., Wagner, D. P., et al. APACHE II: a severity of disease classification system// Critical Care Medicine, 1985; 13: 818-29
16. Loke, Y. K., Kwok, C. S., Niruban, A., Myint, P. K. Value of severity scales in predicting mortality from community-acquired pneumonia: systematic rewiev and meta-analysis// Thorax, 2010; 65: 884-890
17. Lozano, R., Naghavi, N., Foreman, K.,et al. Global and regional mortality from 235causesof death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010// Lancet, 2012; 380 (9859): 2095-128
18. Members of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference Committee (1992). Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis// Critical Care Medicine, 1992; 20: 864-874
19. Mikkelsen, M. E., Miltiades, A. N., Gaieski, D. F., et al. Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock// Critical Care Medicine, 2009; 37: 1670-1677
20. Moine, P., Vercken, J. B., Chevret, S., et al. Severe Community-Acquired Pneumonia: Etiology, Epidemiology, Prognosis Factors//Chest, 1994; 105:1487-1495
21. Neil, A. M., Martin, I. R., Weir, R. et al. Community acquired pneumonia: aetiology and usefullness of severity criteria on admission// Thorax, 1996; 51: 1010-6
22. Odom, S. R. Llactate clearance as a predictor of mortality//The Journal of Tauma and Acute Care Surgery, 2014; 77: 183-4
23. Peake, L. S., Denaley, A., Bailey, M., et al (ARISE Investigators and the ANZICS Clinical Trials Group). Goal-Directed Resuscitation for Patients with Early Septic Shock//New England Journal of Medicine, 2014; 371: 1496-506
24. Peake, S. L., et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med, 2014; 371(16): 1496-506
25. Richards, G.,Levy, H., Laterre, P. F., Feldman, C., Woodward, B., Bates, B. M., Qualy, R. L. CURB-65, PSI, and APACHE II to assess mortality risk in patients with severe sepsis and community acquired pneumonia in PROWESS//Journal of Intensive Care Medicine, 2011; 26(1): 34-40
26. Rivers, E., Nguyen, B., Havstad, S. et al. Early goaldirected therapy in treatment of severe sepsis and septic shock//New England Journal of Medicine, 2001; 345:1368-77
27. Shapiro, N., Howell, M. D., Talmor, D., et al. Serum lactate as a predictor of mortality in emergency department patients with infection// Annals of Emergency Medicine, 2005; 45(5):524-8
28. Sligl, W. I., Marrie, J. T. Severe Community- Acquired Pneumonia// Critical Care Clinics, 2013; 29: 563-601
29. Smith, I., Kumar, P., Molly, S., et al. Base excess and lactate as prognostic indicators for patients admitted to intensive care// Intensive Care Medicine, 2001; 27:74-83
30. Suistomaa, M., Ruokonen, E., Kari, A., et al. Timepattern of lactate and lactate to pyruvate ratio in the first 24 hours of intensive care emergency admissions// Shock, 2000; 14(1): 8-12
31. Wiemken, L. T., Peyrani, P., Ramirez, J. A. Global Changes in the Epidemiology of Community- Acquired Pneumonia// Semin of Respiratory Critical Care Medicine, 2012; 33: 213-219