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Gattinoni L, Vasques F, Camporota L, Meessen J, Romitti F, Pasticci I, Duscio E, Vassalli F, Forni LG, Payen D, Cressoni M, Zanella A, Latini R, Quintel M, Marini JJ. Understanding Lactatemia in Human Sepsis. Potential Impact for Early Management. Am J Respir Crit Care Med 2020; 200:582-589. [PMID: 30985210 DOI: 10.1164/rccm.201812-2342oc] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Rationale: Hyperlactatemia in sepsis may derive from a prevalent impairment of oxygen supply/demand and/or oxygen use. Discriminating between these two mechanisms may be relevant for the early fluid resuscitation strategy.Objectives: To understand the relationship among central venous oxygen saturation (ScvO2), lactate, and base excess to better determine the origin of lactate.Methods: This was a post hoc analysis of baseline variables of 1,741 patients with sepsis enrolled in the multicenter trial ALBIOS (Albumin Italian Outcome Sepsis). Variables were analyzed as a function of sextiles of lactate concentration and sextiles of ScvO2. We defined the "alactic base excess," as the sum of lactate and standard base excess.Measurements and Main Results: Organ dysfunction severity scores, physiologic variables of hepatic, metabolic, cardiac, and renal function, and 90-day mortality were measured. ScvO2 was lower than 70% only in 35% of patients. Mortality, organ dysfunction scores, and lactate were highest in the first and sixth sextiles of ScvO2. Although lactate level related strongly to mortality, it was associated with acidemia only when kidney function was impaired (creatinine >2 mg/dl), as rapidly detected by a negative alactic base excess. In contrast, positive values of alactic base excess were associated with a relative reduction of fluid balance.Conclusions: Hyperlactatemia is powerfully correlated with severity of sepsis and, in established sepsis, is caused more frequently by impaired tissue oxygen use, rather than by impaired oxygen transport. Concomitant acidemia was only observed in the presence of renal dysfunction, as rapidly detected by alactic base excess. The current strategy of fluid resuscitation could be modified according to the origin of excess lactate.
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Affiliation(s)
- Luciano Gattinoni
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Francesco Vasques
- Department of Adult Critical Care, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.,Health Centre for Human and Applied Physiological Sciences, King's College London, London, United Kingdom
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.,Health Centre for Human and Applied Physiological Sciences, King's College London, London, United Kingdom
| | - Jennifer Meessen
- Dipartimento di Ricerche Cardiovascolari, Istituto di Ricovero e Cura a Carattere Scientifico Istituto di Ricerche Farmacologiche "Mario Negri," Milan, Italy
| | - Federica Romitti
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Iacopo Pasticci
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Eleonora Duscio
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Francesco Vassalli
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Lui G Forni
- Department of Intensive Care Medicine, Royal Surrey County Hospital NHS Foundation Trust, Guildford, United Kingdom.,Faculty of Health Sciences, University of Surrey, Guildford, United Kingdom
| | - Didier Payen
- Department of Anaesthesiology and Critical Care, Lariboisière University Hospital, Public Assistance-Paris Hospital, University Paris Diderot, Paris, France
| | - Massimo Cressoni
- Dipartimento di Scienze della Salute, Università degli Studi di Milano Bicocca, Milan, Italy
| | - Alberto Zanella
- Anaesthesia and Critical Care, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Dipartimento di Anestesia, Rianimazione ed Emergenza, Fondazione Istituto di Ricerca e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Roberto Latini
- Dipartimento di Ricerche Cardiovascolari, Istituto di Ricovero e Cura a Carattere Scientifico Istituto di Ricerche Farmacologiche "Mario Negri," Milan, Italy
| | - Michael Quintel
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - John J Marini
- Regions Hospital, St. Paul, Minnesota; and.,University of Minnesota, St. Paul, Minnesota
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Abstract
OBJECTIVE To evaluate the relative importance of increased lactate production as opposed to decreased utilization in hyperlactatemic patients, as well as their relation to glucose metabolism. DESIGN Prospective observational study. SETTING Surgical intensive care unit of a university hospital. PATIENTS Seven patients with severe sepsis or septic shock, seven patients with cardiogenic shock, and seven healthy volunteers. INTERVENTIONS C-labeled sodium lactate was infused at 10 micromol/kg/min and then at 20 micromol/kg/min over 120 mins each. H-labeled glucose was infused throughout. MEASUREMENTS AND MAIN RESULTS Baseline arterial lactate was higher in septic (3.2 +/- 2.6) and cardiogenic shock patients (2.8 +/- 0.4) than in healthy volunteers (0.9 +/- 0.20 mmol/L, p < .05). Lactate clearance, computed using pharmacokinetic calculations, was similar in septic, cardiogenic shock, and controls, respectively: 10.8 +/- 5.4, 9.6 +/- 2.1, and 12.0 +/- 2.6 mL/kg/min. Endogenous lactate production was determined as the initial lactate concentration multiplied by lactate clearance. It was markedly enhanced in the patients (septic 26.2 +/- 10.5; cardiogenic shock 26.6 +/- 5.1) compared with controls (11.2 +/- 2.7 micromol/kg/min, p < .01). C-lactate oxidation (septic 54 +/- 25; cardiogenic shock 43 +/- 16; controls 65 +/- 15% of a lactate load of 10 micromol/kg/min) and transformation of C-lactate into C-glucose were not different (respectively, 15 +/- 15, 9 +/- 18, and 10 +/- 7%). Endogenous glucose production was markedly increased in the patients (septic 14.8 +/- 1.8; cardiogenic shock 15.0 +/- 1.5) compared with controls (7.2 +/- 1.1 micromol/kg/min, p < .01) and was not influenced by lactate infusion. CONCLUSIONS In patients suffering from septic or cardiogenic shock, hyperlactatemia was mainly related to increased production, whereas lactate clearance was similar to healthy subjects. Increased lactate production was concomitant to hyperglycemia and increased glucose turnover, suggesting that the latter substantially influences lactate metabolism during critical illness.
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Mansfield ND, Forni LG. Recently published papers: treating sepsis, measuring troponin and managing the obese. Crit Care 2005; 9:535-7. [PMID: 16356233 PMCID: PMC1414033 DOI: 10.1186/cc3947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Sepsis and septic shock continue to contribute to our workload and stimulate our research activities although many fundamental questions remain. Studies reported on here focus on inotrope use and a novel way of predicting inotrope response. Continuing this theme more fundamental work is reported examining the mitochondrial respiratory chain and the effects of sepsis coupled with interesting work on lactic acidosis. Troponin raises its head again and we are still left quizzing over its value in the ICU. Finally we discuss a paper on the outcome of the obese patient on a general ICU. Like sepsis a continuing challenge.
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Affiliation(s)
- Nicholas D Mansfield
- Specialist Registrar, Department of Critical Care, Worthing General Hospital, Lyndhurst Road, Worthing, West Sussex BN11 2DH, UK
| | - Lui G Forni
- Consultant Intensivist & Nephrologist, Department of Critical Care, Worthing General Hospital, Lyndhurst Road, Worthing, West Sussex BN11 2DH, UK
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Forni LG, McKinnon W, Lord GA, Treacher DF, Peron JMR, Hilton PJ. Circulating anions usually associated with the Krebs cycle in patients with metabolic acidosis. Crit Care 2005; 9:R591-5. [PMID: 16277723 PMCID: PMC1297631 DOI: 10.1186/cc3806] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2005] [Revised: 08/01/2005] [Accepted: 08/12/2005] [Indexed: 01/22/2023]
Abstract
Introduction Acute metabolic acidosis of non-renal origin is usually a result of either lactic or ketoacidosis, both of which are associated with a high anion gap. There is increasing recognition, however, of a group of acidotic patients who have a large anion gap that is not explained by either keto- or lactic acidosis nor, in most cases, is inappropriate fluid resuscitation or ingestion of exogenous agents the cause. Methods Plasma ultrafiltrate from patients with diabetic ketoacidosis, lactic acidosis, acidosis of unknown cause, normal anion gap metabolic acidosis, or acidosis as a result of base loss were examined enzymatically for the presence of low molecular weight anions including citrate, isocitrate, α-ketoglutarate, succinate, malate and d-lactate. The results obtained from the study groups were compared with those obtained from control plasma from normal volunteers. Results In five patients with lactic acidosis, a significant increase in isocitrate (0.71 ± 0.35 mEq l-1), α-ketoglutarate (0.55 ± 0.35 mEq l-1), malate (0.59 ± 0.27 mEq l-1), and d-lactate (0.40 ± 0.51 mEq l-1) was observed. In 13 patients with diabetic ketoacidosis, significant increases in isocitrate (0.42 ± 0.35 mEq l-1), α-ketoglutarate (0.41 ± 0.16 mEq l-1), malate (0.23 ± 0.18 mEq l-1) and d-lactate (0.16 ± 0.07 mEq l-1) were seen. Neither citrate nor succinate levels were increased. Similar findings were also observed in a further five patients with high anion gap acidosis of unknown origin with increases in isocitrate (0.95 ± 0.88 mEq l-1), α-ketoglutarate (0.65 ± 0.20 mEq l-1), succinate (0.34 ± 0.13 mEq l-1), malate (0.49 ± 0.19 mEq l-1) and d-lactate (0.18 ± 0.14 mEq l-1) being observed but not in citrate concentration. In five patients with a normal anion gap acidosis, no increases were observed except a modest rise in d-lactate (0.17 ± 0.14 mEq l-1). Conclusion The levels of certain low molecular weight anions usually associated with intermediary metabolism were found to be significantly elevated in the plasma ultrafiltrate obtained from patients with metabolic acidosis. Our results suggest that these hitherto unmeasured anions may significantly contribute to the generation of the anion gap in patients with lactic acidosis and acidosis of unknown aetiology and may be underestimated in diabetic ketoacidosis. These anions are not significantly elevated in patients with normal anion gap acidosis.
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Affiliation(s)
- Lui G Forni
- Consultant Physician & Intensivist, Department of Critical Care, Worthing Hospital, Worthing, West Sussex, UK
| | - William McKinnon
- Research Fellow, Renal Laboratory, St Thomas' Hospital, London, UK
| | - Gwyn A Lord
- MRC Scientist, MRC Toxicology Unit, Birkbeck College, London, UK
| | - David F Treacher
- Consultant Physician & Intensivist, Renal Laboratory, St Thomas' Hospital, London, UK
| | - Jean-Marie R Peron
- Research Fellow, Department of Chemistry, Kingston University, Surrey, UK
| | - Philip J Hilton
- Consultant Physician & Research Director, Renal Laboratory, St Thomas' Hospital, London, UK
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Abstract
Lactate is released in large quantity from sites of sepsis and inflammation. We asked whether the increased lactate production found in sepsis can be explained by the augmented glycolysis of inflammatory cells. The glycolytic metabolism of rat peritoneal leukocytes was measured following cecal ligation and perforation (CLP) or sham laparotomy. CLP augmented glucose uptake, the pentose phosphate pathway, and glucose oxidation. Lactate output increased from 1.03 +/- 0.05 to 1.20 +/- 0.05 fmol x cell(-1) x min(-1) (P < .001). Total lactate output of peritoneal lavage fluid increased from 7.94 +/- 2.59 to 28.12 +/- 5.60 nmol L x min(-1) (P < .005). The effect of lipopolysaccharide (LPS) on the lactate output of whole blood from 31 critically ill patients was measured. Leukocyte lactate production was calculated by multiple linear regression analysis. Following exposure to LPS, human leukocyte lactate output increased from 0.20 +/- 0.09 to 1.22 +/- 0.14 fmol x cell(-1) x min(-1) (P < .001). This rate of production is so high that it suggests that the lactate output of different tissue beds in sepsis may be affected by their different cell populations and state of activation. This study supports the hypothesis that lactate may be more a product of inflammation than a marker of tissue hypoxia in sepsis.
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Affiliation(s)
- P G Haji-Michael
- Department of Intensive Care, Erasmus Hospital, Brussels, Belgium
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Abstract
Arteriovenous differences in lactate (AVLAC) across the lungs are usually small and close to zero. However, it has recently been reported that the lungs can produce increased amounts of lactate in some patients with acute respiratory distress syndrome (ARDS). The aim of this study was to evaluate lactate production in various types of acute lung injury requiring mechanical ventilation and hemodynamic monitoring. Since the differences involved are usually small, minor errors in lactate measurement could greatly influence AVLAC. Based on an analysis of these errors (see text for details), we averaged five arterial and venous samples for each measurement. We investigated 122 patients: 43 with acute lung injury (ALI), nine with cardiogenic pulmonary edema (CPE), 37 with bronchopneumonia (BPN), seven with single lung transplantation (LTX), and 26 with other causes of respiratory failure (OTHER). There was no difference in arterial lactate between the various groups. AVLAC was higher in patients with ALI than in the other groups (0.20+/-0.23 versus 0.07+/-0.11 mEq/L). In patients with ALI, AVLAC was proportional to the Murray's lung injury score (-0.032+/-0.032x; r = 0.46, p < 0.01). Lung lactate production was calculated as the product of the cardiac index times AVLAC and was significantly higher in patients with ALI than in the other groups (0.69+/-0.88 versus 0.19+/-0.30 mEq/min; p < 0.05). In patients with ALI, lung lactate production was inversely related to the PaO2/FIO2 (1.42 - 0.005x; r = 0.35, p < 0.05) but directly related to the venous admixture (-0.36 + 0.003x; r = 0.49, p < 0.01) and the lung injury score (-0.19 + 0.36x; r = 0.45, p < 0.01). Lung lactate production was not significantly related to arterial lactate levels. These data indicate that AVLAC and lung lactate production can be increased in patients with ARDS but remain within the normal range in other types of respiratory failure.
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Affiliation(s)
- D De Backer
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Belgium
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