Lactic Acid Utilization Compliance
and Outcomes in Sepsis
Ammar A Saati Dr.Budder Siddiqui & Dr.Nashat Rabadi
Contents
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Introduction Objective Methods Results Conclusion
Acknowledgment References
Definitions
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•
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SIRS (Systemic Inflammatory Response Syndrome)
Sepsis Severe Sepsis
Septic Shock Incidence of Severe Sepsis
Mortality of Severe Sepsis
250,000
250
200
150
100
200,000
Deaths/Year
Cases/100,000
300
150,000
100,000
50,000
50
0
AIDS* Colon Breast CHF† Severe
Cancer§
Sepsis‡
†National
0
AIDS*
Breast AMI†
Cancer§
Severe
Sepsis‡
Center for Health Statistics, 2001. §American Cancer Society, 2001. *American Heart Association.
2000. ‡Angus DC et al. Crit Care Med. 2001;29(7):1303-1310.
Introduction
• Severe Sepsis is common, Expensive, and frequently fatal 28‐50%.*
• To risk stratify patients in the proximal phase of illness, may assist clinicians to more effectively manage these patients and improve out comes.
* Angus DC, Linde‐Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001 Jul;29(7):1303–1310
• Elevated Lactic Acid (LA) is strongly associated with Morbidity and Mortality for sepsis patients.*
• Elevated LA is simply a manifestation of organ dysfunction:
– Impaired lactate clearance
– Excessive production *Mikkelsen M. Miltides A. Gaieski D. Goyal M. Fuchs B. Shah C. Bellamy S. Christie J. Serum lacate is associated with mortalilty in severe sepsis independent of organ failure and shock. Crti Care Med 2009 Vol.37 No5; 1670‐77 *Mikkelsen M. Miltides A. Gaieski D. Goyal M. Fuchs B. Shah C. Bellamy S. Christie J. Serum lacate is associated with mortalilty in severe sepsis independent of organ failure and shock. Crti Care Med 2009 Vol.37 No5; 1670‐77 *Mikkelsen M. Miltides A. Gaieski D. Goyal M. Fuchs B. Shah C. Bellamy S. Christie J. Serum lacate is associated with mortalilty in severe sepsis independent of organ failure and shock. Crti Care Med 2009 Vol.37 No5; 1670‐77 • A systematic review supported blood lactate monitoring as being useful for risk assessment in patients admitted acutely to the hospital.*
• For every 1 mmol/L increment of LA the hazard of dying were expected to increase 1.5 times. **
• *Kruse O. Grunnet N. Barfod C. Blood lactate as a predictor for in hospital mortality in patients admitted acutely to hospital: a systematic review; Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2011; 19:74
• **Hisamuddin N, Azlan K,The Use of Laboratory and physiological Parameters in Predicting Mortality in Sepsis Induced Hypotensionand Septic Shock Patients attending the Emergency. Med J Malaysia Vol 67 No 3 June 2012: 259‐264
• Early Directed Goal Therapy EGDT and Surviving Sepsis Guidelines included measuring Lactic Acid.
• EGDT begins with early identification of high risk patients based:
– Hypotension – LA>36mg/dl
*Dellinger R. Levy M. Rhodes A. Annane D. Gerlach H. Opal S. Sevransky J. Sprung C. Douglas I. Jaeschke R. Osborn T. Nunnally M. Townsend S. Reinhart K. Kleinpell R. Angus D. Deutschman C. Machado F. Rubenfeld G. Webb S. Beale R. Vincent J. Moreno R. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic shock; 2012; Crit Care Med Feb 2013 Vol 41 No 2; 580‐637 Objective
• To determine physicians compliance in measuring lactic acid levels in patients admitted with Sepsis.
• To review the mortality outcome associated with elevated lactic acid level.
• To determine the association between elevated lactic acid levels and prolonged hospitalization.
Methodology
• Observational Cohort Study • Total 200 patients (100 SOCH, 100 MHOB)
• Inclusion:
– Age 18 or older
– Sepsis Criteria • Exclusion
– Any patients not fulfilling Sepsis (WBC, Temp)
– Surgical patient • SAS (Statistical Analysis Software)
SOCH
MHOB
178
560
100
78
100
460
Age
Male
Demographics
HTN
CAD
DM
61
33
CHF
23
61
28
16
33
25
Malignancy
COPD
14
23
26
19
HIV
1
2
LA Requested
Control Shock
LA & Mortality
Logistic Regression
LA & Stay
Conclusion
• 57.5% Physicians were compliance with ordering LA.
• High LA level was significantly associated with higher Mortality.
• Considering the low volume population we could not statistically measure the difference in length of stay. Acknowledgment
• Kholoud My Wife.
• Abdulrahman Abudawood MD.
• Dr Henri Woodman MD.
References
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Rivers E. Katranji M. Jaehne K. Brown S. AbouDagher G. Cannon C. Coba V. Early intervention in severe sepsis and septic shock: a review of the evidence one decade later; Minerva Anesteiol June 2012 Vol 78; 712‐24.
Kruse O. Grunnet N. Barfod C. Blood lactate as a predictor for in hospital mortality in patients admitted acutely to hospital: a systemic review; Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2011; 19:74
Dellinger R. Levy M. Rhodes A. Annane D. Gerlach H. Opal S. Sevransky J. Sprung C. Douglas I. Jaeschke R. Osborn T. Nunnally M. Townsend S. Reinhart K. Kleinpell R. Angus D. Deutschman C. Machado F. Rubenfeld G. Webb S. Beale R. Vincent J. Moreno R. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic shock; 2012; Crit Care Med Feb 2013 Vol 41 No 2; 580‐637.
Hisamuddin N. Azlam K. The Use of Laboratory and Physiological Parameters in Predicting Mortality in Sepsis Induced Hypotension and Septic Shock Patients attending The Emergency Department. Med J Malaysia Vol 67 No 3 June 2012; 259‐64.
Nguyen H. Rivers E. Knoblich B. Jacobsen G. Muzzin A. Ressler J. Tomlanovich M. Early lactate clearance is associated with improved out come in severe sepsis and septic shock. Crit Care Med 2004 Vol. 32, No.8; 1637‐42.
Mikkelsen M. Miltides A. Gaieski D. Goyal M. Fuchs B. Shah C. Bellamy S. Christie J. Serum lacate is associated with mortalilty in severe sepsis independent of organ failure and shock. Crti Care Med 2009 Vol.37 No5; 1670‐77.
Wacharasint P. Nakada T. Boyd J. Russell J. Walley K. Normal‐Range blood lactate concentration in Seotic Shock is Prognostic and Predictive; SHOCK Mar 2012 Vol 38 No 1; 4‐10.
National Center for Health Statistics, 2001. §American Cancer Society, 2001. *American
Heart Association. 2000. ‡Angus DC et al. Crit Care Med. 2001;29(7):1303-1310.
THANK YOU
Ammar Saati