Lactate serial measurements and predictive validity of early mortality in trauma patients admitted to the intensive care unit
Patients who have experienced trauma usually develop hypovolemic shock, which determines different levels of tissue hypoperfusion. The determination of lactate levels has been used as a reliable biomarker in the assessment of the magnitude of hypo-perfusion. Additionally, it has been established that lactic clearance in the first 6 h has value as a prognostic measurement for the mortality rate of these patients. However, beyond 6 h its utility is controversial.
To evaluate the predictive capacity of serial lactic acid as well as clearance (at the time admitted, 12 and 24 h) in mortality cases for trauma patients admitted to the ICU.
Materials and methods:
During the period between 2010 and 2014, an observational longitudinal cohort study was conducted with trauma patients admitted to the Intensive Care Unit (ICU) at the Clínica Universidad de la Sabana. The clinical and demographic data was registered in a data base using Microsoft Excel and analyzed in STATA 12® statistical software.
In order to determine the association between each measurement with mortality after seven days, serial measurements of lactic acid were taken at admission time, 12-24 h as well as the clearance of lactic acid at 12 and 24 h.
233 patients participated during the time of the study. The average age was 38 years. 78% of the patients were male, with 21% of the mortality at seven days in the ICU. Among the severity indexes, an average of 14 in APACHE II, 9 in SOFA and 25 in ISS was found. The average of length of stay for survive patients was nine days in contrast to five days of mortality patients.
In brief, the lactic acid average was associated with mortality at seven days in the three time measurements.
On the other hand, the values of the receptor curve operating showed the best performance of the discrimination at 24 h with a 2.35 cut-off point and OR 1.65 (CI 95% 1.27-2.13).
Our findings determined a similar performance of the lactic acid as compared to other studies, especially in the lactic acid level at 24h with relevant discrimination over 2.35 mEq/L at 24. Nonetheless, reverse causality can eventually occur.
2. DiMaggio C, Ayoung-Chee P, Shinseki M, Wilson C, Marshall G, Lee DC, et al. Traumatic injury in the United States: in-patient epidemiology 2000-2011. Injury. 2016;47: 1393-403.
3. Sauaia A, Moore FA, Moore EE, Moser KS, Brennan R, Read R, et al. Epidemiology of trauma deaths: a reassessment. J Trauma. 1995;38:185-93.
4. Ordóñez CA, Pino LF, Tejada JW, Badiel M, Loiza JH, Mata LV, et al. Experience of two first level hospitals in the southwest region of Colombia on the implementation of the Panamerican Trauma Society International Trauma Registry. Rev Col Bras Cir. 2012;39:255-62.
5. Riou B, Landais P, Vivien B, Stell P, Labbene I, Carli P. Distribution of the probability of survival is a strategic issue for randomized trials in critically ill patients. Anesthesiology. 2001;95:56-63.
6. Suarez-de-la-Rica A, Maseda E, Anillo V, Tamayo E, García-Bernedo CA, Ramasco F, et al. Biomarkers (Procalcitonin, C reactive protein, and lactate) as predictors of mortality in surgical patients with complicated intra-abdominal infection. Surg Infect. 2015;16: 346-51.
7. Blow O, Magliore L, Claridge JA, Butler K, Young JS. The golden hour and the silver day: detection and correction of occult hypoperfusion within 24 hours improves outcome from major trauma. J Trauma. 1999;47:964-9.
8. Zhang Z, Xu X, Chen K. Lactate clearance as a useful biomarker for the prediction of all-cause mortality in critically ill patients: a systematic review study protocol. BMJ Open. 2014;4:e004752.
9. Watson NC, Heard SO. The use of lactate as a biomarker. J Intensive Care Med. 2010;25:301-2.
10. Abramson D, Scalea TM, Hitchcock R, Trooskin SZ, Henry SM, Greenspan J. Lactate clearance and survival following injury. J Trauma. 1993;35:584-8, discussion 8-9.
11. Husain FA, Martin MJ, Mullenix PS, Steele SR, Elliott DC. Serum lactate and base deficit as predictors of mortality and morbidity. Am J Surg. 2003;185:485-91.
12. Régnier MA, Raux M, Le Manach Y, Asencio Y, Gaillard J, Devilliers C, et al. Prognostic significance of blood lactate and lactate clearance in trauma patients. Anesthesiology. 2012;117:1276-88.
13. Odom SR, Howell M, Silva GS, Nielsen V, Gupta A, Shapiro N, et al. Lactate clearance as a predictor of mortality in trauma patients. J Trauma Acute Care Surg. 2013;74:999-1004.
14. Dezman ZD, Comer AC, Smith GS, Narayan M, Scalea TM, Hirshon JM. Failure to clear elevated lactate predicts 24-hour mortality in trauma patients. J Trauma Acute Care Surg. 2015;79:580-5.
15. Freitas AD, Franzo O. Lactate as predictor of mortality in polytrauma. Arq Bras Cir Dig. 2015;28:163-6.
16. de Vries HM, Dekker SE, Boer C. Lactate clearance as a predictor of mortality. J Trauma Acute Care Surg. 2014;77:183.
17. Nichol A, Bailey M, Egi M, Pettila V, French C, Stachowski E, et al. Dynamic lactate indices as predictors of outcome in critically ill patients. Critical Care (London, England). 2011;15:R242.
18. Pal JD, Victorino GP, Twomey P, Liu TH, Bullard MK, Harken AH. Admission serum lactate levels do not predict mortality in the acutely injured patient. J Trauma. 2006;60:583-7, discussion 7-9.
19. McNelis J, Marini CP, Jurkiewicz A, Szomstein S, Simms HH, Ritter G, et al. Prolonged lactate clearance is associated with increased mortality in the surgical intensive care unit. Am J Surg. 2001;182:481-5.
20. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818-29.
21. Ferreira FL, Bota DP, Bross A, Melot C, Vincent JL. Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA. 2001;286:1754-8.
22. Baker SP, O'Neill B. The injury severity score: an update. J Trauma. 1976;16:882-5.
23. Antonelli M, Moreno R, Vincent JL, Sprung CL, Mendoça A, Passariello M, et al. Application of SOFA score to trauma patients. Sequentia Organ Failure Assessment. Intensive Care Med. 1999;25:389-94.
24. Cerovic O, Golubovic V, Spec-Marn A, Kremzar B, Vidmar G. Relationship between injury severity and lactate levels in severely injured patients. Intensive Care Med. 2003;29:1300-5.
25. Nguyen HB, Loomba M, Yan JJ, Jacobsen G, Shah K, Otero RM, et al. Early lactate clearance is associated with biomarkers of inflammation, coagulation, apoptosis, organ dysfunction and mortality in severe sepsis and septic shock. J Inflamm. 2010;7:6.
26. Kruse O, Grunnet N, Barfod C. Blood lactate as a predictor for in-hospital mortality in patients admitted acutely to hospital: a systematic review. Scand J Trauma Resusc Emerg Med. 2011;19:74.
27. Kliegel A, Losert H, Sterz F, Holzer M, Zeiner A, Havel C, et al. Serial lactate determinations for prediction of outcome after cardiac arrest. Medicine. 2004;83:274-9.
28. Callaway DW, Shapiro NI, Donnino MW, Baker C, Rosen CL. Serum lactate and base deficit as predictors of mortality in normotensive elderly blunt trauma patients. J Trauma. 2009;66:1040-4.
29. Shapiro NI, Howell MD, Talmor D, Nathanson LA, Lisbon A, Wolfe RE, et al. Serum lactate as a predictor of mortality in emergency department patients with infection. Ann Emerg Med. 2005;45:524-8.
30. Howell MD, Donnino M, Clardy P, Talmor D, Shapiro NI. Occult hypoperfusion and mortality in patients with suspected infection. Intensive Care Med. 2007;33:1892-9.
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