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Mottling Incidence and Mottling Score According to Arterial Lactate Level in Septic Shock Patients.

ABSTRACT: Objectives:Mottling score is estimated from 0-5 according to mottling over the knee and described as clinical evaluation of tissue perfusion. This score was developed with ancient definitions of sepsis without lactate level, a major prognostic parameter when superior to 2 mmol/L. This study describes mottling incidence and mottling score in septic shock patients according to lactate level. Materials and methods:We reanalyzed our prospective study in a French tertiary hospital in the intensive care unit (ICU) which studied mottling score and thermography correlation. Patients admitted to septic shock diagnosis and requiring vasoactive drugs were included. We recorded hemodynamic variables, mottling score, and lactate. Data collection was realized at ICU admission (H0) and after six hours (H6). Results:Forty-three patients were included. Mean age was 67 (±4), mean sequential organ failure assessment (SOFA) score was 11 (8-12), and SAPS II 58 ±20. Mortality rate at day 28 was 30%. Among patients with lactate ?2 mmol/L, mottling was more prevalent in 82.6% vs 47.4% (p value = 0.016), and at H6 mottling score was higher (p value = 0.009). Although, mottling incidence was not different between dead (85%) and survivors (81%; p value = 0.795). Conclusion:A new sepsis definition implies a new epidemiology in mottling according to lactate threshold. Patients with lactate ?2 mmol/L presented a higher incidence and score of mottling. However, mortality was not influenced by mottling in this study. Clinical significance:Arterial lactate is a major prognostic parameter when superior to 2 mmol/L.A new definition of sepsis was published in 2016 with a new paradigm and epidemiology of septic shockPatients with lactate ?2 mmol/L presented a higher incidence and score of mottling.Mottling score is a clinical sign of microcirculatory alteration, related to lactate level in septic shock. How to cite this article:Ferraris A, Bouisse C, Thiollière F, Piriou V, Allaouchiche B. Mottling Incidence and Mottling Score According to Arterial Lactate Level in Septic Shock Patients. Indian J Crit Care Med 2020;24(8):672-676.

SUBMITTER: Ferraris A

PROVIDER: S-EPMC7519602 | biostudies-literature | 2020 Aug

REPOSITORIES: biostudies-literature

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Mottling Incidence and Mottling Score According to Arterial Lactate Level in Septic Shock Patients.

Ferraris Arnaud A Bouisse Camille C Thiollière Fabrice F Piriou Vincent V Allaouchiche Bernard B

Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine 20200801 8

<h4>Objectives</h4>Mottling score is estimated from 0-5 according to mottling over the knee and described as clinical evaluation of tissue perfusion. This score was developed with ancient definitions of sepsis without lactate level, a major prognostic parameter when superior to 2 mmol/L. This study describes mottling incidence and mottling score in septic shock patients according to lactate level.<h4>Materials and methods</h4>We reanalyzed our prospective study in a French tertiary hospital in t ...[more]

PMID: 33024373

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Project description:BACKGROUND:In patients with septic shock, the skin is often chosen for the evaluation of peripheral perfusion and oxygenation. Changes in skin microcirculatory vessel oxygen saturation and relative hemoglobin concentration can be described using a mottling score or captured with hyperspectral imaging. However, the effectiveness of the mottling score in assessing microcirculation remains to be shown. We hypothesize that the mottling score in patients with septic shock is related to skin microcirculatory perfusion indices quantified by hyperspectral imaging, biomarkers that reflect endothelium activation and damage, and clinical outcome. METHODS:Hyperspectral imaging of the knee area was performed in 95 intensive care patients with septic shock enrolled in a single-center observational study to obtain relative oxy/deoxyhemoglobin concentration values and construct anatomical maps of skin microcirculatory saturation. The blood was sampled to obtain concentrations of thrombomodulin, plasminogen activator inhibitor-1 (PAI-1), soluble intercellular adhesion molecule-1 (ICAM-1), soluble vascular cell adhesion molecule-1 (VCAM-1), angiopoietin-2, and syndecan-1. The spectrophotometrically obtained skin microvascular perfusion indices were compared to the mottling score and biomarker concentration. The association between mottling score, skin microcirculatory perfusion indices, and 28-day mortality was also analyzed. RESULTS:Microcirculatory oxygen saturation was significantly lower and total hemoglobin concentration was significantly higher in patients with a mottling score of 2 compared to those with a score of 0 (p?=?0.02), with no difference between other scores. We found an association between microcirculatory oxygen saturation and PAI-1 levels (rho?=?-?0.3; p?=?0.007). Increased mottling score and decreased microcirculatory oxygen saturation were predictive of 28-day mortality (mottling score 2 vs 0: OR 15.31, 95% CI 4.12-68.11; microcirculatory oxygen saturation: OR 0.90, 95% CI 0.85-0.95). Endothelial biomarkers did not increase the predictive value of skin microcirculatory perfusion indices. CONCLUSIONS:Higher mottling scores are associated with lower microcirculatory oxygen saturation but with significant overlap between scores. Microcirculatory oxygen saturation is a quantitative measure of peripheral oxygenation and is more specific than the mottling score in predicting 28-day mortality.

Project description:Background: Some septic shock patients have persistent hyperlactacidemia despite a normal systemic hemodynamics after resuscitation. Central venous oxygen saturation (ScvO2), mean arterial pressure (MAP), and central venous pressure (CVP) cannot be target in subsequent hemodynamic treatments. Vasoplegia is considered to be one of the main causes of oxygen metabolism abnormalities in septic shock patients, and norepinephrine (NE) is the first-line vasopressor in septic shock treatment; its dosage represents the severity of vasoplegia. This study was performed to determine whether vasoplegia, as assessed by NE dosage, can indicate patients' lactate clearance after the completion of resuscitation. Methods: A retrospective study was performed, and 106 patients with septic shock in an intensive care unit were analyzed. Laboratory values and hemodynamic variables were obtained upon completion of resuscitation (H 0) and 6 h after (H 6). Lactate clearance was defined as the percent decrease in lactate from H 0 to H 6. Student's t-test, Mann-Whitney U-test, Chi-square or Fisher's exact tests, logistic regression analysis, and receiver operating characteristic (ROC) curve analysis were performed for statistical analysis. Results: Patients with a mean age of 63.7 ± 13.8 years, baseline APACHE II score of 21.0 ± 5.1, and SOFA score of 12.7 ± 2.7 were enrolled. The study found that after 6-h of resuscitation, lactate clearance (LC) was <10% in 33 patients (31.1%). Patients with 6-h LC <10% compared with 6-h LC ≥ 10% had a higher NE dose (μg·kg-1·min-1) (0.55 [0.36-0.84] vs. 0.25 [0.18-0.41], p < 0.001). Multivariate logistic regression analysis of statistically significant univariate variables showed that NE dose had a significant inverse relationship with 6-h LC < 10%. The cutoff for NE was ≥ 0.32 μg·kg-1·min-1 for predicting 6-h lactate clearance after resuscitation, with a sensitivity of 75.76% and a specificity of 70.00%. Septic shock patients with an NE dose ≥ 0.32 μg·kg-1·min-1, relative to patients with an NE dose < 0.32 μg·kg-1·min-1, had a greater 30-day mortality rate (69.8% vs. 26.4% p < 0.001). Conclusion: Some patients with septic shock had persistent oxygen metabolism disorders after hemodynamic resuscitation. NE dose may indicate vasoplegia and oxygen metabolism disorder. After resuscitation, septic shock patients with high-dose NE have lower lactate clearance and a greater 30-day mortality rate than those with low-dose NE.

Project description:BackgroundThe optimal timing of lactate measurement for septic patients in the intensive care unit (ICU) remains controversial, and whether initiating and repeating the lactate measurement earlier could make a difference for septic patients with an elevated lactate level remains unexplored.MethodsThis was a retrospective observational study that included septic patients with an initial lactate level > 2.0 mmol/L after ICU admission, and all data were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) database. The main exposure of interest was the early lactate measurement, which was defined as an initial lactate level measurement within 1 h after ICU admission. The primary outcome was 28-day mortality.ResultsA total of 2642 eligible subjects were enrolled, including 738 patients who had initial lactate measurements completed within 1 h (EL group) and 1904 patients who had initial lactate measurements completed more than 1 h after ICU admission (LL group). A significant beneficial effect of early lactate measurement in terms of 28-day mortality was observed: the adjusted odds ratio (OR) was 0.69 (95% CI 0.55-0.87; p = 0.001), and the mediation effect of the time to initial vasopressor administration was significant (average causal mediation effect (ACME) - 0.018; 95% CI - 0.005 approximately to - 0.036; p < 0.001). A strong relationship between delayed initial lactate measurement and risk-adjusted 28-day mortality was noted (OR 1.04; 95% CI 1.02-1.05; p < 0.001). Each hour of delay in remeasuring the lactate level was associated with an increase in 28-day mortality in the EL group (OR 1.09; 95% CI 1.04-1.15; p < 0.001). Further analysis demonstrated that repeating the measurement 3 h after the initial lactate measurement led to a significant difference.ConclusionsEarly lactate measurement is associated with a lower risk-adjusted 28-day mortality rate in septic patients with lactate levels > 2.0 mmol/L. A shorter time to the initial vasopressor administration may contribute to this relationship. Repeating the lactate measurement within 3 h after the initial measurement is appropriate for patients whose lactate levels were measured within 1 h of admission.

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Mottling Incidence and Mottling Score According to Arterial Lactate Level in Septic Shock Patients.

Publications

Mottling Incidence and Mottling Score According to Arterial Lactate Level in Septic Shock Patients.

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