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Failure to clear elevated lactate predicts 24-hour mortality in trauma patients.

ABSTRACT: Lactate clearance is a standard resuscitation goal in patients in nontraumatic shock but has not been investigated adequately as a tool to identify trauma patients at risk of dying. Our objective was to determine if trauma patients with impaired lactate clearance have a higher 24-hour mortality rate than patients whose lactate concentration normalizes.A retrospective chart review identified patients who were admitted directly from the scene of injury to an urban trauma center between 2010 and 2013 and who had at least one lactate concentration measurement within 24 hours. Transfers, patients without lactate measurement, and those who were dead on arrival were excluded. Of the 26,545 screened patients, 18,304 constituted the initial lactate measurement population, and 3,887 were the lactate clearance cohorts.Initial lactate had an area under the receiver operating characteristic curve of 0.86 and 0.73 for mortality at 24 hours and in the hospital, respectively. An initial concentration of 3 mmol/L or greater had a sensitivity of 0.86 and a specificity of 0.73 for mortality at 24 hours. The mortality rate among patients with elevated lactate concentrations (n = 2,381; 5.6 [2.8] mmol/L) that did not decline to less than 2.0 mmol/L in response to resuscitative efforts (mean [SD] second measurement, 3.7 [1.9] mmol/L) was nearly seven times higher (4.1% vs. 0.6%, p < 0.001) than among those with an elevated concentration (n = 1,506, 5.3 [2.7]?mmol/L) that normalized (1.4 [0.4]?mmol/L). Logistic regression analysis showed that failure to clear lactate was associated with death more than any other feature (odds ratio, 7.4; 95% confidence interval, 1.5-35.5), except having an Injury Severity Score (ISS) greater than 25 (odds ratio, 8.2; 95% confidence interval, 2.7-25.2).Failure to clear lactate is a strong negative prognostic marker after injury. An initial lactate measurement combined with a second measurement for high-risk individuals might constitute a useful method of risk stratifying injured patients.Prognostic study, level III.

SUBMITTER: Dezman ZD

PROVIDER: S-EPMC4586044 | biostudies-literature | 2015 Oct

REPOSITORIES: biostudies-literature

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Failure to clear elevated lactate predicts 24-hour mortality in trauma patients.

Dezman Zachary D W ZD Comer Angela C AC Smith Gordon S GS Narayan Mayur M Scalea Thomas M TM Hirshon Jon Mark JM

The journal of trauma and acute care surgery 20151001 4

<h4>Background</h4>Lactate clearance is a standard resuscitation goal in patients in nontraumatic shock but has not been investigated adequately as a tool to identify trauma patients at risk of dying. Our objective was to determine if trauma patients with impaired lactate clearance have a higher 24-hour mortality rate than patients whose lactate concentration normalizes.<h4>Methods</h4>A retrospective chart review identified patients who were admitted directly from the scene of injury to an urba ...[more]

PMID: 26402531

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Project description:ImportanceHemorrhagic shock is a common cause of preventable death after injury. Vasopressor administration for patients with blunt trauma and hemorrhagic shock is often discouraged.ObjectiveTo evaluate the association of early norepinephrine administration with 24-hour mortality among patients with blunt trauma and hemorrhagic shock.Design, setting, and participantsThis retrospective, multicenter, observational cohort study used data from 3 registries in the US and France on all consecutive patients with blunt trauma from January 1, 2013, to December 31, 2018. Patients were alive on admission with hemorrhagic shock, defined by prehospital or admission systolic blood pressure less than 100 mm Hg and evidence of hemorrhage (ie, prehospital or resuscitation room transfusion of packed red blood cells, receipt of emergency treatment for hemorrhage control, transfusion of >10 units of packed red blood cells in the first 24 hours, or death from hemorrhage). Blunt trauma was defined as any exposure to nonpenetrating kinetic energy, collision, or deceleration. Statistical analysis was performed from January 15, 2021, to February 22, 2022.ExposureContinuous administration of norepinephrine in the prehospital environment or resuscitation room prior to hemorrhage control, according to European guidelines.Main outcomes and measuresThe primary outcome was 24-hour mortality, and the secondary outcome was in-hospital mortality. The average treatment effect (ATE) of early norepinephrine administration on 24-hour mortality was estimated according to the Rubin causal model. Inverse propensity score weighting and the doubly robust approach with 5 distinct analytical strategies were used to determine the ATE.ResultsA total of 52 568 patients were screened for inclusion, and 2164 patients (1508 men [70%]; mean [SD] age, 46 [19] years; median Injury Severity Score, 29 [IQR, 17-36]) presented with acute hemorrhage and were included. A total of 1497 patients (69.1%) required emergency hemorrhage control, 128 (5.9%) received a prehospital transfusion of packed red blood cells, and 543 (25.0%) received a massive transfusion. Norepinephrine was administered to 1498 patients (69.2%). The 24-hour mortality rate was 17.8% (385 of 2164), and the in-hospital mortality rate was 35.6% (770 of 2164). None of the 5 analytical strategies suggested any statistically significant association between norepinephrine administration and 24-hour mortality, with ATEs ranging from -4.6 (95% CI, -11.9 to 2.7) to 2.1 (95% CI, -2.1 to 6.3), or between norepinephrine administration and in-hospital mortality, with ATEs ranging from -1.3 (95% CI, -9.5 to 6.9) to 5.3 (95% CI, -2.1 to 12.8).Conclusions and relevanceThe findings of this study suggest that early norepinephrine infusion was not associated with 24-hour or in-hospital mortality among patients with blunt trauma and hemorrhagic shock. Randomized clinical trials that study the effect of early norepinephrine administration among patients with trauma and hypotension are warranted to further assess whether norepinephrine is safe for patients with hemorrhagic shock.

Project description:AimsPrevious studies found a relationship between elevated phenylalanine levels and poor cardiovascular outcomes. Potential strategies are available to manipulate phenylalanine metabolism. This study investigated whether increased phenylalanine predicted mortality in critical patients with either acute heart failure (HF) or acute on chronic HF, and its correlation with inflammation and immune cytokines.Methods and resultsThis study recruited 152 subjects, including 115 patients with HF admitted for critical conditions and 37 normal controls. We measured left ventricular ejection fraction (LVEF), plasma concentrations of phenylalanine, C-reactive protein, albumin, pre-albumin, transferrin, and pro-inflammatory and immune cytokines. Acute Physiology and Chronic Health Evaluation (APACHE II), Sequential Organ Failure Assessment (SOFA), and maximal vasoactive-inotropic scores (VISmax ) were calculated. Patients were followed up until death or a maximum of 1 year. The primary endpoint was all-cause death. Of the 115 patients, 37 (32.2%) were admitted owing to acute HF, and 78 (67.8%) were admitted owing to acute on chronic HF; 64 (55.7%) had ST elevation/non-ST elevation myocardial infarction. An LVEF measured during the hospitalization of <40%, 40-50%, and ≥50% was noted in 51 (44.3%), 15 (13.1%), and 49 (42.6%) patients, respectively. During 1 year follow-up, 51 (44.3%) patients died. Death was associated with higher APACHE II, SOFA, and VISmax scores; higher levels of C-reactive protein and phenylalanine; higher incidence of atrial fibrillation and use of inotropic agents; lower cholesterol, albumin, pre-albumin, and transferrin levels; and significant changes in pro-inflammatory and immune cytokines. Phenylalanine levels demonstrated an area under the receiver operating characteristic curve of 0.80 for mortality, with an optimal cut-off value set at 112 μM. Phenylalanine ≥ 112 μM was associated with a higher mortality rate than was phenylalanine < 112 μM (80.5% vs. 24.3%, P < 0.001) [hazard ratio = 5.07 (2.83-9.05), P < 0.001]. The Kaplan-Meier curves revealed that phenylalanine ≥ 112 μM was associated with a lower accumulative survival rate (log rank = 36.9, P < 0.001). Higher phenylalanine levels were correlated with higher APACHE II and SOFA scores, higher C-reactive protein levels and incidence of using inotropic agents, and changes in cytokines suggestive of immunosuppression, but lower levels of pre-albumin and transferrin. Further multivariable analysis showed that phenylalanine ≥ 112 μM predicted death over 1 year independently of age, APACHE II and SOFA scores, atrial fibrillation, C-reactive protein, cholesterol, pre-albumin, transferrin, and interleukin-8 and interleukin-10.ConclusionsElevated phenylalanine levels predicted mortality in critical patients, phenotypically predominantly presenting with HF, independently of traditional prognostic factors and cytokines associated with inflammation and immunity.

Project description:BackgroundExtracellular particles (EPs), particularly extracellular vesicles, play a crucial role in regulating various pathological mechanisms, including immune dysregulations post-trauma. Their distinctive expression of cell-specific markers and regulatory cargo such as cytokines or micro-ribonucleic acid suggests their potential as early biomarkers for organ-specific damage and for identifying patients at risk for complications and mortality. Given the critical need for reliable and easily assessable makers to identify at-risk patients and guide therapeutic decisions, we evaluated the early diagnostic value of circulating EPs regarding outcomes in severely injured multiple-trauma patients.MethodsPlasma samples were collected from 133 severely injured trauma patients (Injury Severity Score (ISS) ≥16) immediately upon arrival at the emergency department (ED). Patients were categorized into survivors and non-survivors. Injury characteristics and outcomes related to sepsis, pneumonia, or early (<1 day after admission) and late mortality were assessed. Circulating EPs, cytokine profiles, and blood counts of platelets and leukocytes were determined. Receiver operating characteristic analyses were conducted.ResultsDespite no significant differences in injury pattern or severity, non-survivors exhibited significantly elevated counts of circulating EPs compared to survivors. The optimal cut-off for EPs <200 nm indicating non-survivors was 17380/µl plasma, with a sensitivity of 77% and a specificity of 61% in predicting in-hospital mortality. Later non-survivors received significantly higher numbers of units of packed red blood cells [8.54 ± 5.45 vs. 1.29 ± 0.36 units], had higher serum lactate [38.00 ± 7.51 vs. 26.98 ± 1.58 mg/dL], significantly lower platelet counts [181.30 ± 18.06 vs. 213.60 ± 5.85 *10³/µL] and lower heart rates [74.50 ± 4.93 vs. 90.18 ± 2.06 beats/minute] upon arrival at the ED compared to survivors.ConclusionOur results demonstrate the high diagnostic potential of elevated concentrations of circulating EPs <200 nm for identifying patients at risk of mortality after severe trauma. This parameter shows comparable sensitivity to established clinical predictors. Early evaluation of EPs concentration could complement assessment markers in guiding early therapeutic decisions.

Project description:We previously reported the added value of 24-hour lactate concentration alone and in combination with 24-hour lactate clearance and lactate concentration at admission for the prediction of inhospital mortality in critically ill patients with sepsis. We aimed to validate this finding.Derivation cohortThe derivation cohort from Leiden, The Netherlands, consisted of 451 critically ill patients with sepsis.Validation cohortThe validation cohort consisted of 4,440 critically ill adult patients with sepsis from the Medical Information Mart for Intensive Care cohort admitted to the ICU of Beth Israel Deaconness Medical Center, Boston, MA, between January 2006 and 2018.Prediction modelPredictors of mortality were: age, chronic comorbidities, length of stay pre-ICU, Glasgow Coma Scale, and Acute Physiology Score. Lactate concentration at 24-hour alone, in combination with 24-hour lactate clearance and in combination with lactate concentration at admission, was added to assess improvement of the prediction model. The outcome was inhospital mortality.ResultsInhospital mortality occurred in 160 patients (36%) in the derivation cohort and in 2,347 patients (53%) in the validation cohort. The Acute Physiology and Chronic Health Evaluation (APACHE) IV model had a moderate discriminative performance (recalibrated C-statistic, 0.62; 95% CI, 0.60-0.63). Addition of 24-hour lactate concentration increased the recalibrated C-statistic to 0.64 (95% CI, 0.62-0.66). The model with 24-hour lactate concentration and lactate concentration at admission showed the best fit as depicted by the smallest Akaike Information Criterion in both the derivation and validation data.ConclusionThe 24-hour lactate concentration and lactate concentration at admission contribute modestly to prediction of inhospital mortality in critically ill patients with sepsis. Future updates and possible modification of APACHE IV should consider the incorporation of lactate concentration at baseline and at 24 hours.

Project description:BackgroundLactate dehydrogenase (LDH) is associated with the prognosis of many diseases, but the relationship between LDH and the poor prognosis (recurrence and death) of acute ischemic stroke (AIS) has not been fully clarified. This study aimed to investigate the association between admission LDH level and poor prognosis in patients with AIS.MethodsThis retrospective study enrolled AIS patients treated in Taizhou Hospital of Zhejiang Province from July 2019 to December 2019. Poor prognosis included AIS recurrence and all-cause death at 3, 6, and 18 months. The correction between LDH and poor prognosis or all-cause death was assessed. Lasso Cox expression and multivariate Cox expression analyses were used to evaluate the association of LDH with the risk of poor prognosis and all-cause death, respectively. A nomogram was constructed to evaluate the predictive Values of LDH for the poor prognosis and all-cause death of AIS.Results732 patients were included in the study. Multivariate analysis shows that admission LDH levels were significantly correlated with poor prognosis [odds ratio (OR),1.003; 95% confidence interval (95% CI), 1.001-1.005; P = 0.001] and all-cause death (OR, 1.005; 95% CI, 1.000-1.009; P = 0.031). The correlation analysis showed that admission LDH level was positively correlated with National Institutes of Health Stroke Scale (NIHSS) score and modified Rankin Scale (mRS) score. Time-dependent receiver operating characteristic (td-ROC) curves analysis showed that the AUC values of admission LDH level for predicting prognosis of AIS patients in 3-month, 6-month, 12-month and 18-month were 0.706 (95% CI, 0.604-0.810), 0.653 (95% CI, 0.583-0.723), 0.616 (95% CI, 0.556-60676) and 0.610 (95% CI, 0.552-0.680), respectively. And td-ROC also showed that the AUC values of admission LDH level for predicting all-cause death of AIS patients in 3-month, 6-month,12-month and 18-month were 0.861 (95% CI, 0.764-0.958), 0.824 (95% CI, 0.753-0.890), 0.726 (95% CI, 0.633-0.819) and 0.715 (95% CI, 0.622-0.807), respectively. The nomograms were constructed to create the predictive models of the poor prognosis and all-cause death of AIS.ConclusionHigher LDH levels are independently associated with poor prognosis and all-cause death of AIS.

Project description:IntroductionCompliance with the ventilator care bundle affects the rate of ventilator-associated pneumonia. It was not known, however, whether compliance with sepsis care bundles has an impact on outcome. The aims of the present study were to determine the rate of compliance with 6-hour and 24-hour sepsis bundles and to determine the impact of the compliance on hospital mortality in patients with severe sepsis or septic shock.MethodsWe conducted a prospective observational study on 101 consecutive adult patients with severe sepsis or septic shock on medical or surgical wards, or in accident and emergency areas at two acute National Health Service Trust Teaching hospitals in England. The main outcome measures were: the rate of compliance with 6-hour and 24-hour sepsis care bundles adapted from the Surviving Sepsis Campaign guidelines on patients' clinical care; and the difference in hospital mortality between the compliant and the non-compliant groups.ResultsThe median age of the patients was 69 years (interquartile range 51 to 78), and 53% were male. The sources of infection were sought and confirmed in 87 of 101 patients. The chest was the most common source (50%), followed by the abdomen (22%). The rate of compliance with the 6-hour sepsis bundle was 52%. Compared with the compliant group, the non-compliant group had a more than twofold increase in hospital mortality (49% versus 23%, relative risk (RR) 2.12 (95% confidence interval (CI) 1.20 to 3.76), P = 0.01) despite similar age and severity of sepsis. Compliance with the 24-hour sepsis bundle was achieved in only 30% of eligible candidates (21/69). Hospital mortality was increased in the non-compliant group from 29% to 50%, with a 76% increase in risk for death, although the difference did not reach statistical significance (RR 1.76 (95% CI 0.84 to 3.64), P = 0.16).ConclusionNon-compliance with the 6-hour sepsis bundle was associated with a more than twofold increase in hospital mortality. Non-compliance with the 24-hour sepsis bundle resulted in a 76% increase in risk for hospital death. All medical staff should practise these relatively simple, easy and cheap bundles within a strict timeframe to improve survival rates in patients with severe sepsis and septic shock.

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Failure to clear elevated lactate predicts 24-hour mortality in trauma patients.

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Failure to clear elevated lactate predicts 24-hour mortality in trauma patients.

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