Rebound Hyperlactatemia Tied to Trauma Death

CHANDLER, ARIZ. — Rebound elevation of serum lactate is a significant predictor of morbidity and mortality in critically ill trauma patients, based on a prospective study of 698 patients.

“Rebound hyperlactatemia better predicts mortality than [do] admission lactate values alone,” Dr. Megan Brenner said at the annual meeting of the Eastern Association for the Surgery of Trauma.

A stepwise regression analysis of patients showed that rebound hyperlactatemia increases mortality 2.5-fold, said Dr. Brenner of the University of Maryland, Baltimore. Mortality was 15.8% in patients with rebound hyperlactatemia vs. 8.2% in those who achieved lactate normalization without a second abnormal lactate elevation.

Of the 698 patients, 538 had high admission serum lactate (greater than 1.6 mmol/L) with subsequent lactate normalization (0.5-1.6 mmol/L), 43 had a normal admission lactate, and 117 had an elevated admission lactate that never normalized. Of those 538 patients, 305 achieved lactate normalization and did not have another abnormal elevation, and 233 had a second abnormal elevation (mean 2.2 mmol/L) at a mean of 31 hours after initial normalization and 94 hours after admission. The mean age of the cohort was 43 years, 78% were male, and 84% had suffered a blunt trauma.

Patients with rebound hyperlactatemia also had significantly greater number of ICU days (odds ratio 11.8) and ventilator days (OR 9.8) and significantly greater hospital length of stay (OR 11.4).

Rebound hyperlactatemia was a better predictor of mortality (OR 2.5) than were admission lactate values (OR 1.07) in the analysis, which adjusted for age, sex, Injury Severity Score (ISS), Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation (APACHE). The mean ISS was 29 for the cohort, mean SOFA was 3.7, and mean APACHE was 12.

An analysis of all 698 patients showed that admission lactate levels correlate with mortality only (OR 1.07) and do not affect ICU days, ventilator days, and length of stay. Dr. Brenner recommends checking serum lactate values daily for a minimum of the first 4 hospital days. If lactate levels are used as an end point of resuscitation, continued monitoring of the patient is warranted. Frequent lactate monitoring may be needed to identify at-risk subgroups of patients.

Invited discussant Dr. Carina Biggs, a surgeon at Kings County Hospital Center, N.Y., asked why lactate rather than base deficit was evaluated, as the latter has been shown to be a marker of mortality.

Dr. Brenner said that lactate levels rather than base deficit were evaluated because prior research has shown that they are more useful than base deficit for predicting outcome in trauma patients.

Disclosures: Dr. Brenner and Dr. Biggs disclosed no relevant conflicts of interest.

My Take

Also Consider Vital Signs, Mechanism

Either lactate or base deficit is a good marker to initially screen injured patients for severity of injury. But two things must be factored into the equation. First, these values are only an indicator and should be used with physical examination and vital signs. Second, the value of the base deficit as an outcome predictor depends on the mechanism of injury, being most useful for patients sustaining penetrating trauma (Am. Surg. 2002;68:689-94).

Other studies have correlated the severity of the base deficit with outcomes, so the abnormal value alone is not as meaningful as the magnitude of abnormality (J. Trauma 1988;10:1464-7). It may be helpful to keep this in mind, as this study seems to have a lot of patients with elevated lactate levels, and those levels remained high in many of those patients.

GRACE S. ROZYCKI, M.D., is chief of the division of trauma/surgical critical care, department of surgery, Emory University, Atlanta.

Vitals

CHANDLER, ARIZ. — Rebound elevation of serum lactate is a significant predictor of morbidity and mortality in critically ill trauma patients, based on a prospective study of 698 patients.

“Rebound hyperlactatemia better predicts mortality than [do] admission lactate values alone,” Dr. Megan Brenner said at the annual meeting of the Eastern Association for the Surgery of Trauma.

A stepwise regression analysis of patients showed that rebound hyperlactatemia increases mortality 2.5-fold, said Dr. Brenner of the University of Maryland, Baltimore. Mortality was 15.8% in patients with rebound hyperlactatemia vs. 8.2% in those who achieved lactate normalization without a second abnormal lactate elevation.

Of the 698 patients, 538 had high admission serum lactate (greater than 1.6 mmol/L) with subsequent lactate normalization (0.5-1.6 mmol/L), 43 had a normal admission lactate, and 117 had an elevated admission lactate that never normalized. Of those 538 patients, 305 achieved lactate normalization and did not have another abnormal elevation, and 233 had a second abnormal elevation (mean 2.2 mmol/L) at a mean of 31 hours after initial normalization and 94 hours after admission. The mean age of the cohort was 43 years, 78% were male, and 84% had suffered a blunt trauma.

Patients with rebound hyperlactatemia also had significantly greater number of ICU days (odds ratio 11.8) and ventilator days (OR 9.8) and significantly greater hospital length of stay (OR 11.4).

Rebound hyperlactatemia was a better predictor of mortality (OR 2.5) than were admission lactate values (OR 1.07) in the analysis, which adjusted for age, sex, Injury Severity Score (ISS), Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation (APACHE). The mean ISS was 29 for the cohort, mean SOFA was 3.7, and mean APACHE was 12.

An analysis of all 698 patients showed that admission lactate levels correlate with mortality only (OR 1.07) and do not affect ICU days, ventilator days, and length of stay. Dr. Brenner recommends checking serum lactate values daily for a minimum of the first 4 hospital days. If lactate levels are used as an end point of resuscitation, continued monitoring of the patient is warranted. Frequent lactate monitoring may be needed to identify at-risk subgroups of patients.

Invited discussant Dr. Carina Biggs, a surgeon at Kings County Hospital Center, N.Y., asked why lactate rather than base deficit was evaluated, as the latter has been shown to be a marker of mortality.

Dr. Brenner said that lactate levels rather than base deficit were evaluated because prior research has shown that they are more useful than base deficit for predicting outcome in trauma patients.

Disclosures: Dr. Brenner and Dr. Biggs disclosed no relevant conflicts of interest.

My Take

Also Consider Vital Signs, Mechanism

Either lactate or base deficit is a good marker to initially screen injured patients for severity of injury. But two things must be factored into the equation. First, these values are only an indicator and should be used with physical examination and vital signs. Second, the value of the base deficit as an outcome predictor depends on the mechanism of injury, being most useful for patients sustaining penetrating trauma (Am. Surg. 2002;68:689-94).

Other studies have correlated the severity of the base deficit with outcomes, so the abnormal value alone is not as meaningful as the magnitude of abnormality (J. Trauma 1988;10:1464-7). It may be helpful to keep this in mind, as this study seems to have a lot of patients with elevated lactate levels, and those levels remained high in many of those patients.

GRACE S. ROZYCKI, M.D., is chief of the division of trauma/surgical critical care, department of surgery, Emory University, Atlanta.

Vitals

CHANDLER, ARIZ. — Rebound elevation of serum lactate is a significant predictor of morbidity and mortality in critically ill trauma patients, based on a prospective study of 698 patients.

“Rebound hyperlactatemia better predicts mortality than [do] admission lactate values alone,” Dr. Megan Brenner said at the annual meeting of the Eastern Association for the Surgery of Trauma.

A stepwise regression analysis of patients showed that rebound hyperlactatemia increases mortality 2.5-fold, said Dr. Brenner of the University of Maryland, Baltimore. Mortality was 15.8% in patients with rebound hyperlactatemia vs. 8.2% in those who achieved lactate normalization without a second abnormal lactate elevation.

Of the 698 patients, 538 had high admission serum lactate (greater than 1.6 mmol/L) with subsequent lactate normalization (0.5-1.6 mmol/L), 43 had a normal admission lactate, and 117 had an elevated admission lactate that never normalized. Of those 538 patients, 305 achieved lactate normalization and did not have another abnormal elevation, and 233 had a second abnormal elevation (mean 2.2 mmol/L) at a mean of 31 hours after initial normalization and 94 hours after admission. The mean age of the cohort was 43 years, 78% were male, and 84% had suffered a blunt trauma.

Patients with rebound hyperlactatemia also had significantly greater number of ICU days (odds ratio 11.8) and ventilator days (OR 9.8) and significantly greater hospital length of stay (OR 11.4).

Rebound hyperlactatemia was a better predictor of mortality (OR 2.5) than were admission lactate values (OR 1.07) in the analysis, which adjusted for age, sex, Injury Severity Score (ISS), Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation (APACHE). The mean ISS was 29 for the cohort, mean SOFA was 3.7, and mean APACHE was 12.

An analysis of all 698 patients showed that admission lactate levels correlate with mortality only (OR 1.07) and do not affect ICU days, ventilator days, and length of stay. Dr. Brenner recommends checking serum lactate values daily for a minimum of the first 4 hospital days. If lactate levels are used as an end point of resuscitation, continued monitoring of the patient is warranted. Frequent lactate monitoring may be needed to identify at-risk subgroups of patients.

Invited discussant Dr. Carina Biggs, a surgeon at Kings County Hospital Center, N.Y., asked why lactate rather than base deficit was evaluated, as the latter has been shown to be a marker of mortality.

Dr. Brenner said that lactate levels rather than base deficit were evaluated because prior research has shown that they are more useful than base deficit for predicting outcome in trauma patients.

Disclosures: Dr. Brenner and Dr. Biggs disclosed no relevant conflicts of interest.

My Take

Also Consider Vital Signs, Mechanism

Either lactate or base deficit is a good marker to initially screen injured patients for severity of injury. But two things must be factored into the equation. First, these values are only an indicator and should be used with physical examination and vital signs. Second, the value of the base deficit as an outcome predictor depends on the mechanism of injury, being most useful for patients sustaining penetrating trauma (Am. Surg. 2002;68:689-94).

Other studies have correlated the severity of the base deficit with outcomes, so the abnormal value alone is not as meaningful as the magnitude of abnormality (J. Trauma 1988;10:1464-7). It may be helpful to keep this in mind, as this study seems to have a lot of patients with elevated lactate levels, and those levels remained high in many of those patients.

GRACE S. ROZYCKI, M.D., is chief of the division of trauma/surgical critical care, department of surgery, Emory University, Atlanta.

Vitals