Información de la revista
Vol. 41. Núm. 1.
Investigación en Sepsis
Páginas 55-56 (Enero - Febrero 2017)
Compartir
Compartir
Descargar PDF
Más opciones de artículo
Vol. 41. Núm. 1.
Investigación en Sepsis
Páginas 55-56 (Enero - Febrero 2017)
Scientific Letter
DOI: 10.1016/j.medin.2016.06.005
Acceso a texto completo
Toward a personalized response approach in sepsis 4.0
Hacia una estrategia de respuesta personalizada en sepsis 4.0
Visitas
...
C. de Haroa, E. Torrentsa, R. Ferrerb, A. Artigasa, A. Rodriguezc, I. Martin-Loechesd,
Autor para correspondencia
drmartinloeches@gmail.com

Corresponding author.
a Critical Care Center, Parc Taulí Hospital-Sabadell, CIBERes, Parc Tauli s/n. Sabadell, Barcelona, Spain
b Critical Care Center, Vall d’Hebron Hospital, CIBERes, Pss Villanova s/n, Barcelona, Spain
c Critical Care Department, Joan XXIII University Hospital, CIBERes, Dr. Mallafrè Guasch, 4, Tarragona, Spain
d Multidisciplinary Intensive Care Research Organization (MICRO), CIBERes, Wellcome Trust HRB Clinical Research, Department of Clinical Medicine, Trinity Centre for Health Sciences, St James's University Hospital, St James's Street, Dublin, Ireland
Información del artículo
Texto completo
Bibliografía
Descargar PDF
Estadísticas
Figuras (1)
Texto completo
Dear Editor,

Sepsis is one of the leading causes of mortality worldwide.1 However, mortality rates widely vary among different countries when patients have been enrolled in prospective septic shock trials.2 For this and other reason, including sepsis recognition, new definitions of septic shock were launched. Now, shock is a clinical condition defined by a vasopressor requirement to maintain a mean arterial pressure of 65mm Hg or greater and serum lactate level greater than 2mmol/L (>18mg/dL) in the absence of hypovolemia.3 Our hypothesis is that lactate level is not sufficient for defining shock progression but timing within the first 24h of resuscitation. The aim of the present study is to determine the prognostic value of a predefined lactate clearance in the first 24h of sepsis. A total of 544 consecutive patients with sepsis were included from a tertiary University Hospital (Parc Tauli Hospital, Sabadell, Spain). The vast majority presented an abdominal (37.9%) or respiratory source of sepsis (31.3%) and 62.8% were admitted through emergency department. Patients presented were 66.6 (SD 14.8) years old, 63.2% male and presented an APACHE II score of 18.4 (SD 7.7) with a mortality rate of 29.8%. We calculated the optimal cutoff for a lower mortality during the first 24h of sepsis using the Youden index. With our data, this optimal cutoff was 10%, with a sensitivity of 51% and specificity of 71%. Patients with a lactate clearance10% within the first 24h of sepsis had a lower mortality in a univariate analysis than patients without that clearance (21.2% vs. 39.1%; p<0.001). We adjusted lactate clearance for confounding factors, as initial lactate value and severity (APACHE II score), and we observed that lactate clearance10% during the first 24h of sepsis was identified as a protective factor for mortality (OR 0.49: 95% CI 0.30–0.81; p<0.05) (Fig. 1). We, therefore, analyzed the relationship between lactate clearance and the fulfillment of the Surviving Sepsis Campaign (SSC) bundles. The group of patients with a lactate clearance10% trended toward a better fulfillment of SCC bundles (5.1% vs. 2.2%; p=0.12). We performed a multivariate analysis including all the SCC bundles (antibiotic treatment, fluid administration, vasopressors and initial lactate value and fluid administration) and lactate clearance10% (OR 6.41; 95% CI 2.01–20.45; p<0.05) was associated independently with a lower mortality. Despite the new incorporation of serum lactate levels for shock definition, we consider that the most important approach to reflect current ICU mortality would be the use of lactate clearance in the definition.4 Therefore, a personalized approach is lacking in the current definitions and a lactate clearance equal or greater than 10% within the first 24h of sepsis evolution is independently associated with lower mortality. Nguyen et al.5 discovered that early lactate clearance within the first 6h was associated with a decrease mortality however the 10% decrease was chosen after analyzing sensitivity and specificity of different thresholds. In our study, the implementation of a mathematical model (Youden index) helped us to find the “ideal threshold”. Interestingly, in accordance with recently published studies, in our cohort, fluid administration during the first hours of sepsis is independently associated with lactate clearance.6 Effort should be done to identify patients with shock and determinant of response, rather than to flag them only shocked.

Figure 1.

Odds ratio for mortality in patients included in the study. Abbreviation: OR, odds ratio.

(0,04MB).
Funding

None declared.

Conflict of interest

The authors have no conflict of interest to disclose.

References
[1]
I. Martin-Loeches, M.M. Levy, A. Artigas.
Management of severe sepsis: advances, challenges, and current status.
Drug Des Dev Ther, 9 (2015), pp. 2079-2088
[2]
M.M. Levy, A. Rhodes, G.S. Phillips, S.R. Townsend, C.A. Schorr, R. Beale, et al.
Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study.
Intensive Care Med, 40 (2014), pp. 1623-1633
[3]
M. Singer, C.S. Deutschman, C.W. Seymour, M. Shankar-Hari, D. Annane, M. Bauer, et al.
The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).
JAMA, 315 (2016), pp. 801-810
[4]
S. Trefler, A. Rodríguez, I. Martín-Loeches, V. Sanchez, J. Marín, M. Llauradó, et al.
Estrés oxidativo en pacientes inmunocompetentes con neumonía comunitaria grave. Un estudio piloto.
Med Intensiva, 38 (2014), pp. 73-82
[5]
H.B. Nguyen, E.P. Rivers, B.P. Knoblich, G. Jacobsen, A. Muzzin, J.A. Ressler, et al.
Early lactate clearance is associated with improved outcome in severe sepsis and septic shock.
Crit Care Med, 32 (2004), pp. 1637-1642
[6]
A. Rhodes, G. Phillips, R. Beale, M. Cecconi, J.D. Chiche, D. De Backer, et al.
The Surviving Sepsis Campaign bundles and outcome: results from the International Multicentre Prevalence Study on Sepsis (the IMPreSS study).
Intensive Care Med, 41 (2015), pp. 1620-1628
Copyright © 2016. Elsevier España, S.L.U. y SEMICYUC
Idiomas
Medicina Intensiva

Suscríbase a la newsletter

Opciones de artículo
Herramientas
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

es en
Política de cookies Cookies policy
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here.