LABORATORIO DE URGENCIAS

 

 

 

 

28. BMC Med Inform Decis Mak. 2019 Dec 30;19(1):284. doi: 10.1186/s12911-019-1015-5.

A Bayesian decision support sequential model for severity of illness predictors and intensive care admissions in pneumonia.

Baez AA(1)(2)(3), Cochon L(4), Nicolas JM(4).

Author information:

(1)University of Barcelona, Barcelona, Spain.

(2)Universidad Nacional Pedro Henriquez Urena (UNPHU), Postgraduate Studies,  Santo Domingo, Dominican Republic

(3)Medical College of Georgia, Department of Emergency Medicine, Augusta, GA, USA.

(4)University of Barcelona, Barcelona, Spain.

BACKGROUND: Community-acquired pneumonia (CAP) is one of the leading causes of  morbidity and mortality in the USA. Our objective was to assess the predictive value on critical illness and disposition of a sequential Bayesian Model that integrates Lactate and procalcitonin (PCT) for pneumonia.
METHODS: Sensitivity and specificity of lactate and PCT attained from pooled meta-analysis data. Likelihood ratios calculated and inserted in Bayesian/ Fagan nomogram to calculate posttest probabilities. Bayesian Diagnostic Gains (BDG) were analyzed comparing pre and post-test probability. To assess the value of integrating both PCT and Lactate in Severity of Illness Prediction we built a model that combined CURB65 with PCT as the Pre-Test markers and later integrated the Lactate Likelihood Ratio Values to generate a combined CURB 65 + Procalcitonin + Lactate Sequential value.
RESULTS: The BDG model integrated a CUBR65 Scores combined with Procalcitonin (LR+ and LR-) for Pre-Test Probability Intermediate and High with Lactate Positive Likelihood Ratios. This generated for the PCT LR+ Post-test Probability (POSITIVE TEST) Posterior probability: 93% (95% CI [91,96%]) and Post Test Probability (NEGATIVE TEST) of: 17% (95% CI [15-20%]) for the Intermediate subgroup and 97% for the high risk sub-group POSITIVE TEST: Post-Test probability: 97% (95% CI [95,98%]) NEGATIVE TEST: Post-test probability: 33% (95% CI [31,36%]) . ANOVA analysis for CURB 65 (alone) vs CURB 65 and PCT (LR+) vs CURB 65 and PCT (LR+) and Lactate showed a statistically significant difference (P value = 0.013).
CONCLUSIONS: The sequential combination of CURB 65 plus PCT with Lactate yielded statistically significant results, demonstrating a greater predictive value for severity of illness thus ICU level care.

DOI: 10.1186/s12911-019-1015-5

PMCID: PMC6937994

PMID: 31888590 [Indexed for MEDLINE]

 

30. Int J Mol Sci. 2019 Dec 25;21(1):157. doi: 10.3390/ijms21010157.

Tumor Microenvironment: A Metabolic Player that Shapes the Immune Response.

Cassim S(1), Pouyssegur J(1)(2).

Author information:

(1)Department of Medical Biology, Centre Scientifique de Monaco, CSM, 98000 Monaco.

(2)University Côte d'Azur, IRCAN, CNRS, Centre A. Lacassagne, 06189 Nice, France.

Immune cells survey and patrol throughout the body and sometimes take residence in niche environments with distinct cellular subtypes and nutrients that may fluctuate from those in which they matured. Rooted in immune cell physiology are metabolic pathways and metabolites that not only deliver substrates and energy for growth and survival, but also instruct effector functions and cell differentiation. Unlike cancer cells, immune cells are not subject to a "Darwinian evolutionary pressure" that would allow them to adapt to developing tumors but are often irrevocably affected to local nutrient deprivation. Thus, immune cells must metabolically adapt to these changing conditions in order to perform their necessary functions. On the other hand, there is now a growing appreciation that metabolic changes occurring in cancer cells can impact on immune cell functionality and contribute to tumor immune evasion, and as such, there is a considerable and growing interest in developing techniques that target metabolism for immunotherapy. In this review, we discuss the metabolic plasticity displayed by innate and adaptive immune cells and highlight how tumor-derived lactate and tumor acidity restrict immunity. To our knowledge, this review outlines the most recent insights on how tumor microenvironment metabolically instructs immune responsiveness.

DOI: 10.3390/ijms21010157

PMCID: PMC6982275

PMID: 31881671 [Indexed for MEDLINE]

 

31. Sensors (Basel). 2019 Dec 17;19(24):5576. doi: 10.3390/s19245576.

Enhanced Performance of Reagent-Less Carbon Nanodots Based Enzyme Electrochemical Biosensors.

Bravo I(1)(2), Gutiérrez-Sánchez C(1)(2), García-Mendiola T(1)(2)(3), Revenga-Parra M(1)(2)(3), Pariente F(1)(3), Lorenzo E(1)(2)(3).

Author information:

(1)Departamento de Química Analítica y Análisis Instrumental, Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain.

(2)Instituto Madrileño de Estudios Avanzados en Nanociencia (IMDEA-Nanociencia), Faraday, 9, Campus UAM, Cantoblanco, 28049 Madrid, Spain.

(3)Institute for Advanced Research in Chemical Sciences (IAdChem), Universidad Autónoma de Madrid, 28049 Madrid, Spain.

This work reports on the advantages of using carbon nanodots (CNDs) in the development of reagent-less oxidoreductase-based biosensors. Biosensor responses are based on the detection of H2O2, generated in the enzymatic reaction, at 0.4 V. A simple and fast method, consisting of direct adsorption of the bioconjugate, formed by mixing lactate oxidase, glucose oxidase, or uricase with CNDs, is employed to develop the nanostructured biosensors. Peripherical amide groups enriched CNDs are prepared from ethyleneglycol bis-(2-aminoethyl ether)-N,N,N',N'-tetraacetic acid and tris(hydroxymethyl)aminomethane, and used as precursors. The bioconjugate formed between lactate oxidase and CNDs was chosen as a case study to determine the analytical parameters of the resulting L-lactate biosensor. A linear concentration range of 3.0 to 500 µM, a sensitivity of 4.98 × 10-3 µA·µM-1, and a detection limit of 0.9 µM were obtained for the L-lactate biosensing platform. The reproducibility of the biosensor was found to be 8.6%. The biosensor was applied to the L-lactate quantification in a commercial human serum sample. The standard addition method was employed. L-lactate concentration in the serum extract of 0.9 ± 0.3 mM (n = 3) was calculated. The result agrees well with the one obtained in 0.9 ± 0.2 mM, using a commercial spectrophotometric enzymatic kit.

DOI: 10.3390/s19245576

PMCID: PMC6960740

PMID: 31861148 [Indexed for MEDLINE]

 

32. Biochem Med (Zagreb). 2020 Feb 15;30(1):011001. doi: 10.11613/BM.2020.011001. Epub 2019 Dec 15.

High anion gap metabolic acidosis caused by D-lactate: mind the time of blood collection.

Weemaes M(1), Hiele M(2), Vermeersch P(1)(3).

Author information:

(1)Clinical Department of Laboratory Medicine, UZ Leuven, Leuven, Belgium.

(2)Clinical Department of Gastroenterology, UZ Leuven, Leuven, Belgium.

(3)Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium.

 

INTRODUCTION: D-lactic acidosis is an uncommon cause of high anion gap acidosis.

MATERIALS AND METHODS: A 35-year old woman was admitted to the emergency room  with somnolence, drowsiness, dizziness, incoherent speech and drunk appearance.  Her past medical history included a Roux-en-Y bypass. Point-of-care venous blood  analysis revealed a high anion gap acidosis. Based on the clinical presentation, routine laboratory results and negative toxicology screening, D-lactate and 5-oxoprolinuria were considered as the most likely causes of the high anion gap acidosis. Urine organic acid analysis revealed increased lactate, but no 5-oxoproline. Plasma D-lactate was < 1.0 mmol/L and could not confirm D-lactic acidosis.
WHAT HAPPENED: Further investigation revealed that the blood sample for D-lactate was drawn 12 hours after admission, which might explain the false-negative result. Data regarding the half-life of D-lactate are, however, scarce. During a second admission, one month later, D-lactic acidosis could be confirmed with an anion gap of 40.7 mmol/L and a D-lactate of 21.0 mmol/L measured in a sample collected at the time of admission.
MAIN LESSON: The time of blood collection is of utmost importance to establish the diagnosis of D-lactic acidosis due to the fast clearance of D-lactate in the human body.

DOI: 10.11613/BM.2020.011001

PMCID: PMC6904971

PMID: 31839728 [Indexed for MEDLINE]

 

39. Interact Cardiovasc Thorac Surg. 2019 Dec 1;29(6):955-959. doi: 10.1093/icvts/ivz197.

Somatic and cerebral near infrared spectroscopy for the monitoring of perfusion during neonatal cardiopulmonary bypass.

Bojan M(1), Bonaveglio E(2), Dolcino A(3), Mirabile C(1).

Author information:

(1)Department of Anesthesiology, Congenital Cardiac Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France.

(2)Pediatric Cardiac Intensive Care, Regina Margherita Hospital, Città della Salute, Torino, Italy.

(3)Department of Anesthesiology, Necker-Enfants Malades Hospital, Paris, France.

OBJECTIVES: The somatic-cerebral regional oxygen saturation (rSO2) gradient has the potential to reveal a low cardiac output state at an early stage, when systemic vascular resistance increases in order to maintain cerebral perfusion, and results in a drop in somatic rSO2. We hypothesized that during neonatal cardiopulmonary bypass (CPB), the somatic-cerebral rSO2 gradient can also signal poor perfusion, as assessed by an increase in lactate concentration.

METHODS: In a retrospective review of neonatal bypass records, we investigated the association between the somatic-cerebral rSO2 gradient and serial lactate measurements. The somatic-cerebral rSO2 gradient, i.e. the area between the somatic and cerebral rSO2, was calculated for each CPB time interval between 2 lactate measurements, using the trapezoidal method. The association between the somatic-cerebral rSO2 gradient and lactate variation was explored using a mixed model for repeated measurements adjusted for the CPB temperature across intervals.
RESULTS: A total of 94 CPB intervals were analysed in 24 neonates, median age 6 days, median weight 3.1 kg. The median lactate variation per interval was +0.2 mmol l-1 (range -1.5 to +2.7), the median somatic-cerebral gradient was 0 (range -1229% min to +2049% min) and the median CPB temperature was 29.5°C (IQR 28.1-33.4). There was an independent association between the lactate increase and the somatic-cerebral rSO2 gradient (regression coefficient = -0.0006 ± 0.0002, P = 0.009).
CONCLUSIONS: A decrease in the somatic-cerebral rSO2 gradient was associated with an increase in lactate concentration, suggesting that the somatic-cerebral rSO2 gradient is a useful monitoring tool for the adequacy of perfusion during neonatal CPB.

DOI: 10.1093/icvts/ivz197

PMID: 31384917 [Indexed for MEDLINE]

40. Med Sci Sports Exerc. 2019 Dec;51(12):2595-2602. doi: 10.1249/MSS.0000000000002077.

New On-Water Test for Assessment of Blood Lactate Response to Exercise in Elite Kayakers.

Pilotto AM(1)(2), Rasica L(3)(4), Scalise G(1), Annoni S(1), LA Torre A(4)(5), Marzorati M(1), Porcelli S(1).

Author information:

(1)Institute of Biomedical Technologies, National Research Council, Segrate, ITALY.

(2)Department of Medicine, University of Udine, Udine, ITALY.

(3)Institute of Molecular Bioimaging and Physiology, National Research Council, Segrate, ITALY.

(4)Department of Biomedical Science for Health, University of Milano, Milan, ITALY.

(5)IRCCS Istituto Ortopedico Galeazzi, Milan, ITALY.

PURPOSE: Lactate thresholds are physiological parameters used to train athletes and monitor performance or training. Currently, the assessment of lactate thresholds in kayakers is performed in a laboratory setting utilizing specific ergometers; however, laboratory tests differ from on-water evaluation for several reasons. The aim of this study was to assess reliability and validity of a new on-water incremental test for the assessment of blood lactate response to exercise in flat-water kayakers. Maximal lactate steady state test (MLSS) was used as criterion measurement.
METHODS: Eleven junior (16.5 ± 1.9 yr) élite flat-water kayakers performed: i)  an incremental cardiopulmonary test up to voluntary exhaustion on a stationary kayak ergometer to determine peak oxygen uptake; ii) an on-water 1000-m distance trial (T1000) to record best performance time and average speed (S1000); iii) two repetitions of on-water incremental kayaking test (WIK test); iv) several repetitions of on-water constant speed tests to determine MLSS. Speed, HR, and blood lactate concentrations were determined during on-water tests.
RESULTS: The best performance time in T1000 was 262 ± 13 s, corresponding to an S1000 of 3.82 ± 0.19 m·s. Lactate threshold determined by modified Dmax method (LTDmod) during WIK test was 2.78 ± 1.02 mmol·L and the corresponding speed (SLT) was 3.34 ± 0.16 m·s. Test-retest reliability, calculated on SLT, was strong (ICC = 0.95 and r = 0.93). MLSS test corresponded to 3.06 ± 0.68 mmol·L and was reached at a speed (SMLSS) of 3.36 ± 0.14 m·s. Correlation coefficient between SLT and SMLSS was 0.90 (P = 0.0001). Interestingly, a significant correlation (r = 0.96, P < 0.0001) was observed between SLT and S1000.
CONCLUSIONS: The WIK test showed good reliability and validity for the assessment of speed corresponding to LTDmod in flat-water kayakers and it could be a useful tool to monitor athletic performance. The speed value at LTDmod nicely predicted performance on 1000 m.

DOI: 10.1249/MSS.0000000000002077

PMID: 31246717 [Indexed for MEDLINE]

43. Dis Markers. 2019 Nov 26;2019:1578502. doi: 10.1155/2019/1578502. eCollection 2019.

The Impact of Serum Glucose on the Predictive Value of Serum Lactate for Hospital Mortality in Critically Ill Surgical Patients.

Chen X(1), Bi J(1)(2), Zhang J(1)(2), Du Z(1)(2), Ren Y(1)(2), Wei S(1), Ren F(1)(2), Wu Z(2), Lv Y(1)(2), Wu R(1).

Author information:

(1)National Local Joint Engineering Research Center for Precision Surgery &

Regenerative Medicine, Shaanxi Provincial Center for Regenerative Medicine and Surgical Engineering, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China.

(2)Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China.

BACKGROUND: Lactate has been widely used as a risk indicator of outcomes in critically ill patients due to its ready measurement and good predictive ability. However, the interconnections between lactate metabolism and glucose metabolism have not been sufficiently explored, yet. In this study, we aimed to investigate whether glucose levels could influence the predictive ability of lactate and design a more comprehensive strategy to assess the in-hospital mortality of critically ill patients.
METHODS: We analyzed the clinical data of 293 critically ill patients. The primary outcome was in-hospital mortality. The logistic regression analysis and the area under the receiver operating characteristic curve (AUROC) were applied to evaluate the predictive ability of lactate in association with glucose.
RESULTS: The lactate level showed significant association with in-hospital mortality, and its predictive ability was also comparable to other prognostic scores such as the SOFA score and APACHE II score. We further divided 293 patients into three groups based on glucose levels: low-glucose group (<7 mmol/L), medium-glucose group (7-9 mmol/L), and high-glucose group (>9 mmol/L). The lactate level was associated with in-hospital mortality in the low- and high- glucose groups, but not in the medium-glucose group, whereas the SOFA score and APACHE II score were associated with in-hospital mortality in all three glucose groups. The AUROC of lactate in the medium-glucose group was also the lowest among the three glucose groups, indicating a decrease in its predictive ability.
CONCLUSIONS: Our findings demonstrated that the predictive ability of lactate to assess in-hospital mortality could be influenced by glucose levels. In the medium glucose level (i.e., 7-9 mmol/L), lactate was inadequate to predict in-hospital mortality and the SOFA score; the APACHE II score should be utilized as a complementation in order to obtain a more accurate prediction.

DOI: 10.1155/2019/1578502

PMCID: PMC6899272

PMID: 31885730 [Indexed for MEDLINE]

45. 
    PLoS One. 2019 Nov 22;14(11):e0225541. doi: 10.1371/journal.pone.0225541. eCollection 2019.

Oxygen delivery, oxygen consumption and decreased kidney function after cardiopulmonary bypass.

Hendrix RHJ(1), Ganushchak YM(1), Weerwind PW(1)(2).

Author information:

(1)Department of Extra-Corporeal Circulation, Maastricht University Medical Centre+, Maastricht, the Netherlands.

(2)Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands.

INTRODUCTION: Low oxygen delivery during cardiopulmonary bypass is related to a range of adverse outcomes. Previous research specified certain critical oxygen delivery levels associated with acute kidney injury. However, a single universal critical oxygen delivery value is not sensible, as oxygen consumption has to be considered when determining critical delivery values. This study examined the associations between oxygen delivery and oxygen consumption and between oxygen delivery and kidney function in patients undergoing cardiopulmonary bypass.
METHODS: Oxygen delivery, oxygen consumption and kidney function decrease were retrospectively studied in 65 adult patients.
RESULTS: Mean oxygen consumption was 56 ± 8 ml/min/m2, mean oxygen delivery was 281 ± 39 ml/min/m2. Twenty-seven patients (42%) had an oxygen delivery lower than the previously mentioned critical value of 272 ml/min/m2. None of the patients developed acute kidney injury according to RIFLE criteria. However, in 10 patients (15%) a decrease in the estimated glomerular filtration rate of more than 10% was noted, which was not associated with oxygen delivery lower than 272 ml/min/m2. Eighteen patients had a strong correlation (r >0.500) between DO2 and VO2, but this was not related to low oxygen delivery. Central venous oxygen saturation (77 ± 3%), oxygen extraction ratio (21 ± 3%) and blood lactate levels at the end of surgery (1.2 ± 0.3 mmol/l) showed not to be indicative of insufficient oxygen delivery either.
CONCLUSIONS: This study could not confirm an evident correlation between O2 delivery and O2 consumption or kidney function decrease, even at values below previously specified critical levels. The variability in O2 consumption however, is an indication that every patient has individual O2 needs, advocating for an individualized O2 delivery goal.

DOI: 10.1371/journal.pone.0225541

PMCID: PMC6874338

PMID: 31756180 [Indexed for MEDLINE]

49. Scand J Trauma Resusc Emerg Med. 2019 Nov 12;27(1):103. doi: 10.1186/s13049-019-0681-8.

Prognostic ability of the sequential organ failure assessment score in accidental hypothermia: a multi-institutional retrospective cohort study.

Kandori K(1), Okada Y(2)(3), Matsuyama T(4), Morita S(5), Ehara N(6), Miyamae N(7), Jo T(8), Sumida Y(9), Okada N(4)(10), Watanabe M(4), Nozawa M(11), Tsuruoka A(12), Fujimoto Y(13), Okumura Y(14), Kitamura T(15), Iiduka R(1).

Author information:

(1)Department of Emergency and Critical Care Medicine, Japanese Red Cross Society, Kyoto Daini Hospital, Kyoto, Japan.

(2)Department of Emergency and Critical Care Medicine, Japanese Red Cross Society, Kyoto Daini Hospital, Kyoto, Japan. yokada-kyf@umin.ac.jp.

(3)Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan. yokada-kyf@umin.ac.jp.

(4)Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.

(5)Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan.

(6)Department of Emergency, Japanese Red Cross Society, Kyoto Daiichi Red Cross Hospital, Kyoto, Japan.

(7)Department of Emergency Medicine, Rakuwa-kai Otowa Hospital, Kyoto, Japan.

(8)Department of Emergency Medicine, Uji-Tokushukai Medical Center, Uji, Japan.

(9)Department of Emergency Medicine, North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan.

(10)Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan.

(11)Department of Emergency and Critical Care Medicine, Saiseikai Shiga Hospital, Ritto, Japan.

(12)Department of Emergency and Critical Care Medicine, Kyoto Min-Iren Chu Hospital,  Japan.

(13)Department of Emergency Medicine, Yodogawa Christian Hospital, Osaka, Japan.

(14)Department of Emergency Medicine, Fukuchiyama City Hospital, Fukuchiyama, Japan.

(15)Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan.

BACKGROUND: Severe accidental hypothermia (AH) is life threatening. Thus, prognostic prediction in AH is essential to rapidly initiate intensive care. Several studies on prognostic factors for AH are known, but none have been established. We clarified the prognostic ability of the Sequential Organ Failure Assessment (SOFA) score in comparison with previously reported prognostic factors among patients with AH.
METHODS: The J-point registry database is a multi-institutional retrospective cohort study for AH in 12 Japanese emergency departments. From this registry, we enrolled patients who were treated at the intensive care unit (ICU) in various critical care medical centers. In-hospital mortality was the primary outcome. We investigated the discrimination ability of each candidate prognostic factor and the in-hospital mortality by applying the logistic regression models with areas under the receiver operating characteristic curve (AUROC) with 95% confidence interval (CI).
RESULTS: Of the 572 patients with AH registered in the J-point registry, 220 were eligible for the analyses. The in-hospital mortality was 23.2%. The AUROC of the SOFA score (0.80; 95% CI: 0.72-0.86) was the highest among all factors.
The other factors were serum potassium (0.65; 95% CI: 0.55-0.73), lactate (0.67; 95% CI: 0.57-0.75), quick SOFA (qSOFA) (0.55; 95% CI: 0.46-0.65), systemic inflammatory responsesyndrome (SIRS) (0.60; 95% CI: 0.50-0.69), and 5A severity scale (0.77; 95% CI: 0.68-0.84).
DISCUSSION: Although serum potassium and lactate had relatively good discrimination ability as mortality predictors, the SOFA score had slightly better discrimination ability. The reason is that lactate and serum potassium were mainly reflected by hemodynamic state; conversely, the SOFA score is a comprehensive score of organ failure, basing on six different scores from the respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems. Meanwhile, the qSOFA and SIRS scores underestimated the severity, with low discrimination abilities for mortality.
CONCLUSIONS: The SOFA score demonstrated better discrimination ability as a mortality predictor among all known prognostic factors in patients with AH.

DOI: 10.1186/s13049-019-0681-8

PMCID: PMC6849316

PMID: 31718708 [Indexed for MEDLINE].

50. Crit Care. 2019 Nov 11;23(1):351. doi: 10.1186/s13054-019-2625-0.

Early lactate measurement is associated with better outcomes in septic patients with an elevated serum lactate level.

Chen H(1), Zhao C(1), Wei Y(1), Jin J(2).

Author information:

(1)Department of Intensive Care Medicine, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou, 215000, Jiangsu, China.

(2)Department of Intensive Care Medicine, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou, 215000, Jiangsu, China.

BACKGROUND: The 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.
METHODS: This 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.
RESULTS: A 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.
CONCLUSIONS: Early 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.

DOI: 10.1186/s13054-019-2625-0

PMCID: PMC6849274

PMID: 31711512 [Indexed for MEDLINE]

 

52. BMC Pregnancy Childbirth. 2019 Nov 6;19(1):405. doi: 10.1186/s12884-019-2552-8.

A before and after study of the impact on obstetric and perinatal outcomes following the introduction of an educational package of fetal heart rate monitoring education coupled with umbilical artery lactate sampling in a low resource setting labor ward in South Africa.

Allanson ER(1)(2), Pattinson RC(3), Nathan EA(4), Dickinson JE(4).

Author information:

(1)Division of Obstetrics and Gynaecology, Faculty of Health and Medical Sciences M550, The University of Western Australia, 35 Stirling Hwy, Crawley, WA, 6009, Australia.

(2)SAMRC/UP Maternal and Infant Health Care Strategies Unit, Department of Obstetrics and Gynaecology, University of Pretoria, Unit Private Bag X323 Arcadia, Pretoria,  South Africa..

(3)SAMRC/UP Maternal and Infant Health Care Strategies Unit, Department of Obstetrics and Gynaecology, University of Pretoria, Unit Private Bag X323 Arcadia, Pretoria,  South Africa.

(4)Division of Obstetrics and Gynaecology, Faculty of Health and Medical Sciences M550, The University of Western Australia, 35 Stirling Hwy, Crawley, WA, 6009, Australia.

INTRODUCTION: Rates of cesarean section (CS) are increasing and abnormal fetal heart rate tracing and concern about consequent acidosis remain one of the most common indications for primary CS. Umbilical artery (UA) lactate sampling provides clinicians with point of care feedback on CTG interpretation and intrapartum care and may result in altered future practice.
MATERIALS AND METHODS: From 3rd March - 12th November 2014 we undertook a before and after study in Pretoria, South Africa, to determine the impact of introducing a clinical package of fetal heart rate monitoring education and prompt feedback with UA cord lactate sampling, using a hand-held meter, on maternal and perinatal outcomes.
RESULTS: Nine hundred thirty-six consecutive samples were analyzed (pre n = 374 and post n = 562). There was no difference in mean lactate (4.6 mmol/L [95%CI 4.4-4.8] compared with 4.9 mmol/L [95%CI 4.7-5.1], p = 0.089). Suspected fetal compromise was reduced in the post-intervention period: 30·2% vs 22·1%, aOR 0·71, 95% CI 0·52-0·96, p = 0·027. Cesarean section rates were significantly reduced in the univariate analysis: pre- 40·3% vs post-intervention 31·6% (p = 0·007). This reduction remained significant when adjusted for previous cesarean section, primiparity, maternal HIV infection and preterm birth (aOR 0·72, 95%CI 0·54-0·98, p = 0·035). Neonatal outcomes did not differ between the two groups.
CONCLUSION: The introduction of a clinical practice package of fetal heart rate monitoring education combined with routine UA cord lactate sampling has the potential to reduce the cesarean section rate without increasing adverse neonatal outcomes in a low-resource setting.

DOI: 10.1186/s12884-019-2552-8

PMCID: PMC6836471

PMID: 31694569 [Indexed for MEDLINE]

53. Cardiovasc Pathol. 2020 Mar-Apr;45:107161. doi: 10.1016/j.carpath.2019.107161.

Epub 2019 Nov 5.

Comparison of heat monitoring-based myocardial protection strategy with classic myocardial protection method in isolated coronary artery bypass surgery patients.

Gojayev F(1), Solgun HA(2), Ak K(3), Midi A(4), Canillioglu Y(5).

Author information:

(1)Department of Cardiovasculer Surgery, Altınbas University Medicine Faculty, Medical Park Bahcelievler Hospital, Istanbul, Turkey.

(2)Department of Pediatrics, Altınbas University Medicine Faculty, Medical Park Bahcelievler Hospital, Istanbul, Turkey. Electronic address: hsynavn@gmail.com.

(3)Department of Pediatric Cardiovasculer Surgery, Marmara University Medicine Faculty, Istanbul, Turkey.

(4)Department of Patology, Bahçeşehir University Medicine Faculty, Istanbul, Turkey.

(5)Department of Histology, Bahçeşehir University Medicine Faculty, Istanbul, Turkey.

OBJECTIVE: In this study, we aimed to compare patients who have a myocardial protection strategy based on myocardial temperature monitorization with those who had myocardial protection with conventional intermittent cardioplegia.
METHODS: Twenty-six patients undergoing coronary artery bypass graft surgery were included into the study. Patients were prospectively grouped into two; myocardial protection based on temperature monitoring (group 1, n = 11) and those who had cardioplegia every 20 min (group 2, n = 15) during aortic cross-clamping. In all patients, cold blood cardioplegia was used. Coronary sinus blood sampling was performed immediately before aortic cross-clamping, after 2, 20, and 40 min of aortic clamping and tumor necrosis factor-alpha, malondialdehyde, creatinine kinase-myocardial band isoenzyme (MB), troponin I, lactate, and pH were studied. In addition, myocardial biopsy was taken before and immediately after cross-clamping to evaluate cardiomyocyte apoptosis with caspase-3 tunnel immunostaining.
RESULTS: There were no differences in clinical parameters like early mortality, extubation time, inotropic requirements, postoperative drainage, intensive care unit, and hospitalization time between two groups. In addition, blood and blood products were similar in two groups. In group 2, after cross-clamping, troponin I and creatinine kinase-MB values were significantly higher than the other group. In myocardial biopsies, the caspase immunostaining score, before removal of aortic cross-clamp was significantly higher in group 2 than the samples taken before aortic clamping.
CONCLUSION: Our results show that there is no difference between temperature-based myocardial protection strategy with conventional intermittent cardioplegia delivery. We think that the number of patients in our study is less and that the patient population is not a homogeneous structure is the most important limiting factor of our study. Increasing the number of patients, with particularly those who have myocardial dysfunction would help augment the possible different effects of two cardioplegic techniques on myocardial protection.

DOI: 10.1016/j.carpath.2019.107161

PMID: 31810046 [Indexed for MEDLINE]

54. Burns. 2019 Dec;45(8):1775-1782. doi: 10.1016/j.burns.2019.02.014. Epub 2019 Nov 2.

Associations between clinical characteristics and the development of multiple organ failure after severe burns in adult patients.

Ogura A(1), Tsurumi A(2), Que YA(3), Almpani M(2), Zheng H(4), Tompkins RG(1), Ryan CM(2), Rahme LG(5).

Author information:

(1)Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 340 Thier Research Building, 50 Blossom Street, Boston MA 02114, USA.

(2)Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 340 Thier Research Building, 50 Blossom Street, Boston MA 02114, USA; Shriners Hospitals for Children, 51 Blossom St., Boston, MA 02114, USA.

(3)Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland.

(4)Biostatistics Center, Massachusetts General Hospital, and Harvard Medical School, 50 Staniford St., Boston, MA 02114, USA.

(5)Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 340 Thier Research Building, 50 Blossom Street, Boston MA 02114, USA; Shriners Hospitals for Children, 51 Blossom St., Boston, MA 02114, USA; Department of Microbiology and Immunobiology, Harvard Medical School, 77 Ave. Louis Pasteur, Boston, MA 02114, USA. Electronic address:

To determine the association between potential risk factors and multiple organ failure (MOF) in severe burn adult patients, we performed a secondary analysis of data from the "Inflammation and the Host Response to Injury" database, which included patients from six burn centers in the United States between 2003 and 2009. Three hundred twenty-two adult patients (aged ≥16 years) with severe burns (≥20.0% total body surface area [TBSA]) were included. MOF was defined according to the Denver score. Potential risk factors were analyzed for their association with MOF. Models were built using multivariable logistic regression analysis. Eighty-eight patients (27.3%) developed MOF during the study period. We found that TBSA, age, and inhalation injury were significant risk factors for MOF. This predictive model showed good performance, with the total area under the receiver operating characteristic curve being 0.823. Moreover, among patients who developed MOF, inhalation injury was significantly associated with the development of MOF in the acute phase (within three days of injury) (adjusted odds ratio 3.1; 95% confidence interval 1.1-8.3). TBSA, age, lactate, and Denver score within 24h were associated with the late phase development of MOF. Thus, we have identified key risk factors for the onset of MOF after severe burn injury. Our findings contribute to the understanding of individualized treatment and will potentially allow for efficient allocation of resources and a lower threshold for admission to an intensive care unit, which can prevent the development of MOF and eventually reduce mortality.

DOI: 10.1016/j.burns.2019.02.014

PMID: 31690472 [Indexed for MEDLINE]

55. 
    Medicine (Baltimore). 2019 Nov;98(48):e18025. doi: 10.1097/MD.0000000000018025.

Efficacy and safety of acupuncture as a complementary therapy for sepsis: A protocol of systematic review and meta-analysis.

Xian J(1), Wang L(2), Zhang C(1), Wang J(1), Zhu Y(1), Yu H(2), Zhang X(2), Tan Q(2).

Author information:

(1)Affiliated Hospital of Shandong University of Traditional Chinese Medicine.

(2)Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China.

INTRODUCTION: Sepsis is a physiological, pathological, and biochemical syndrome caused by infection. Acupuncture may be useful for sepsis. This systematic review aims to assess the efficacy and safety of acupuncture as a complementary therapy for sepsis.
METHODS AND ANALYSIS: We will search PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure (CNKI), Wan Fang Database, Chinese Biomedicine (CBM) database, VIP database, and TCM Literature Analysis and Retrieval Database from inception to October 31, 2019 to identify any eligible study. We include all randomized controlled trials (RCTs) without any limitation of blinding or publication language, exclude cohort studies and case reports. Two reviewers will independently select studies, extract and manage data. The primary outcomes include the mortality at 28 days, acute physiology, and chronic health evaluation II scores. The secondary outcomes include the tumor necrosis factor α (TNF-α) counts, interleukin 6 (IL-6) counts, interleukin 10 (IL-10) counts, procalcitonin (PCT), lactic acid, the level of T cell subsets (CD3+, CD4+, CD8+, CD4+/CD8+), monocytes of human leukocyte antigen DR (HLA-DR), C-reactive protein (CRP), the numeration of leukocyte, intra-abdominal pressure, and adverse events or reactions.
Statistical analyses will be performed using the Review Manager V.5.3 and R packages Metafor. We will use the Cochrane risk of bias tool for randomized trials to assess the risk of bias of included studies.
ETHICS AND DISSEMINATION: This study will not involve personal information. Ethical approval will not be required. We will publish the results in a peer-reviewed journal.
PROSPERO TRIAL REGISTRATION NUMBER: CRD42019141491.

DOI: 10.1097/MD.0000000000018025

PMCID: PMC6890293

PMID: 31770216 [Indexed for MEDLINE]

59. 
    Arch Dis Child Fetal Neonatal Ed. 2020 Jan;105(1):4-7. doi: 10.1136/archdischild-2019-317417. Epub 2019 Oct 30.

Parents of babies who participated in an invasive clinical study report a positive experience: the Glucose in Well Babies (GLOW) study.

Cumberpatch AR(1), Weston PJ(1), Harding JE(2), Harris DL(3)(4).

Author information:

(1)Newborn Intensive Care Unit, Waikato District Health Board, Hamilton, New Zealand.

(2)Liggins Institute, University of Auckland, Auckland, New Zealand.

(3)Liggins Institute, University of Auckland, Auckland, New Zealand Deborah.

(4)School of Nursing, Midwifery and Health Practice, Faculty of Health, Victoria University of Wellington, Wellington, New Zealand.

OBJECTIVE: There is a paucity of data about normal blood metabolite concentrations in healthy babies, in part because of a reluctance to undertake non-therapeutic invasive testing in newborns. The Glucose in Well Babies study (GLOW) sought to describe blood glucose, lactate and beta-hydroxybutyrate concentrations in healthy term babies over the first 5 postnatal days. We also sought to understand both parents' experience of participation in this invasive non-therapeutic study.
DESIGN, SETTING, PATIENTS AND INTERVENTIONS: Eligible babies were healthy, term, appropriately grown singletons born in a birthing centre, hospital or home within the greater Hamilton area and then discharged home. Babies had subcutaneous continuous glucose monitoring placed soon after birth, up to 14 heel-prick blood samples, twice-daily home visits and parents were asked to record all feeds. At study completion, both parents were asked to independently complete a questionnaire about their experience.
RESULTS: All eligible babies completed the study and every parent completed thequestionnaire (65 fathers, 66 mothers). Parents reported they liked contributing to improving healthcare (126/131, 96%) and support from the GLOW team (119/131, 91%). Nearly all (127/131, 97%) would participate in GLOW again if they had another eligible baby, and all would recommend GLOW to family and friends.
Two-thirds of parents (87/131, 66%) reported that participation had made them more likely to contribute to clinical research in the future.
CONCLUSIONS: Non-therapeutic studies involving invasive procedures in healthy term babies are feasible, and parents were positive about their experience.

DOI: 10.1136/archdischild-2019-317417

PMID: 31666312 [Indexed for MEDLINE]

63. 
    PLoS One. 2019 Oct 24;14(10):e0224016. doi: 10.1371/journal.pone.0224016. eCollection 2019.

Clinical impact of intraoperative hyperlactatemia during craniotomy.

Romano D(1), Deiner S(1)(2)(3), Cherukuri A(4), Boateng B(5), Shrivastava R(2), Mocco J(2), Hadjipanayis C(2), Yong R(2), Kellner C(2), Yaeger K(2), Lin HM(6), Brallier J(7).

Author information:

(1)Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.

(2)Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.

(3)Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.

(4)University of Central Florida College of Medicine, Orlando, FL, United States of America.

(5)Alabama College of Osteopathic Medicine, Dothan, AL, United States of America.

(6)Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.

(7)Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America.

OBJECT: Patients often develop markedly elevated serum lactate levels during craniotomy although the reason for this is not entirely understood. Elevated lactate levels have been associated with poor outcomes in critically ill septic shock patients, as well as patients undergoing abdominal and cardiac surgeries.
We investigated whether elevated lactate in craniotomy patients is associated with neurologic complications (new neurological deficits) as well as systemic complications.
METHODS: We performed a cohort study of elective craniotomy patients. Demographic and intraoperative data were collected, as well as three timed intraoperative arterial lactatevalues. Additional lactate, creatinine and troponin values were collected immediately postoperatively as well as 12 and 24 hours postoperatively. Assessment for neurologic deficit was performed at 6 hours and 2 weeks postoperatively. Hospital length-of-stay and 30-day mortality were collected.
RESULTS: Interim analysis of 81 patients showed that no patient had postoperative myocardial infarction, renal failure, or mortality within 30 days of surgery. There was no difference in the incidence of new neurologic deficit in patients with or without elevated lactate (10/26, 38.5% vs. 15/55 27.3%, p = 0.31). Median length of stay was significantly longer in patients with elevated lactate (6.5 vs. 3 days, p = 0.003). Study enrollment was terminated early due to futility (futility index 0.16).
CONCLUSION: Elevated intraoperative serum lactate was not associated with new postoperative neurologic deficits, other end organ events, or 30 day mortality.
Serum lactate was related to longer hospital stay.

DOI: 10.1371/journal.pone.0224016

PMCID: PMC6812741

PMID: 31647826 [Indexed for MEDLINE]

64. Crit Care Clin. 2020 Jan;36(1):115-124. doi: 10.1016/j.ccc.2019.08.009. Epub 2019 Oct 18.

Lactate: Where Are We Now?

Bakker J(1), Postelnicu R(2), Mukherjee V(2).

Author information:

(1)Division of Pulmonary Critical Care, and Sleep Medicine, New York University School of Medicine, Bellevue Hospital, 462 First Avenue | NBV-10W18, New York, NY 10016, USA; Department of Pulmonology and Critical Care, Columbia University Medical Center, New York, NY, USA; Department Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Intensive Care, Pontificia Universidad Católica de Chile, Santiago, Chile. Electronic address:

 (2)Division of Pulmonary Critical Care, and Sleep Medicine, New York University School of Medicine, Bellevue Hospital, 462 First Avenue | NBV-10W18, New York, NY 10016, USA.

There is a tight relationship between lactate levels (and its changes over time) with morbidity and mortality and the presence of tissue hypoxia/hypoperfusion in both models of shock and clinical studies. These findings have placed lactate in the center of guiding resuscitation in patients with increased lactate levels. However, given the complex metabolism and clearance of lactate, especially in sepsis, the actual use of lactate is more complex than suggested by some guidelines. By using other markers of tissue hypoperfusion together with lactate levels provides a more solid framework to guide the initial hours of resuscitation.

DOI: 10.1016/j.ccc.2019.08.009

PMID: 31733674 [Indexed for MEDLINE]

 

66. Biomark Med. 2019 Dec;13:1469-1480. doi: 10.2217/bmm-2019-0174. Epub 2019 Oct 17.

 

Prognostic performance of pancreatic stone protein in critically ill patients with sepsis.

García de Guadiana-Romualdo L(1), Albaladejo-Otón MD(1), Berger M(2), Jiménez-Santos E(1), Jiménez-Sánchez R(3), Esteban-Torrella P(1), Rebollo-Acebes S(3), Hernando-Holgado A(1), Ortín-Freire A(3), Trujillo-Santos J(4).

Author information:

(1)Clinical Chemistry Laboratory, Santa Lucía Hospital, Cartagena, Spain.

(2)Bayer AG, Pharmaceuticals Division, R&D Clinical Sciences, Aprather Weg 18a, 42096 Wuppertal, Germany.

(3)Intensive Care Unit, Santa Lucía Hospital, Cartagena, Spain.

(4)Internal Medicine Department, Santa Lucía Hospital, Cartagena, Spain.

Aim: To assess the prognostic value for 28-day mortality of PSP in critically ill patients with sepsis. Material & methods: 122 consecutive patients with sepsis were enrolled in this study. Blood samples were collected on admission and day 2. Results: On admission, the combination of PSP and lactate achieved an area under the receiver operating characteristic (AUC-ROC) of 0.796, similar to sequential organ failure assessment score alone (AUC-ROC: 0.826). On day 2, PSP was the biomarker with the highest performance (AUC-ROC: 0.844), although lower (p = 0.041) than sequential organ failure assessment score (AUC-ROC: 0.923).
Conclusion: The combination of PSP and lactate and PSP alone, on day 2, have a good performance for prognosis of 28-day mortality and could help to identify patients who may benefit most from tailored intensive care unit management.

DOI: 10.2217/bmm-2019-0174

PMID: 31621373 [Indexed for MEDLINE]

71. 
    J Perinatol. 2020 Jan;40(1):56-62. doi: 10.1038/s41372-019-0520-9. Epub 2019 Oct 2.

Marked variability in intrapartum electronic fetal heart rate patterns: association with neonatal morbidity and abnormal arterial cord gas.

Polnaszek B(1), López JD(2), Clark R(2), Raghuraman N(2), Macones GA(3), Cahill AG(3).

Author information:

(1)Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, MO, USA.

 (2)Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, MO, USA.

(3)The University of Texas at Austin Dell Medical School, Austin, TX, USA.

OBJECTIVE: Investigate marked variability in fetal heart rate (FHR) patterns before delivery and its association with neonatal morbidity and abnormal arterial cord gases.
STUDY DESIGN: Prospective cohort of laboring patients at term. Composite neonatal morbidity (respiratory distress, mechanical ventilation, suspected sepsis, meconium aspirationsyndrome, therapeutic hypothermia, hypoxic-ischemic encephalopathy, seizure, and death) and abnormal arterial cord gases (pH < 7.10, lactate ≥ 4 mmol/L, base deficit < -12 mEq/L) were assessed with multivariable logistic regression.
RESULT: Three hundred and ninety (4.5%) neonates had marked variability in FHR patterns before delivery. There was no difference in composite neonatal morbidity (aRR 1.22; 95% CI 0.91-1.63), though neonates with marked variability in FHR patterns were more likely to have a respiratory distress (aRR 1.85; 95% CI 1.25-2.70). There was an increased risk of composite abnormal arterial cord gases (aRR 1.66; 95% CI 1.47-1.88).
CONCLUSION: Marked variability in FHR patterns was not associated with composite neonatal morbidity but was associated with abnormal arterial cord gases.

DOI: 10.1038/s41372-019-0520-9

PMCID: PMC7202403

PMID: 31578422 [Indexed for MEDLINE]

 

76. Medicine (Baltimore). 2019 Oct;98(41):e17479. doi: 10.1097/MD.0000000000017479.

Stratified and prognostic value of admission lactate and severity scores in patients with community-acquired pneumonia in emergency department: A single-center retrospective cohort study.

Zhou H(1), Lan T(2), Guo S(1).

Author information:

(1)Department of Emergency Medicine, Beijing Chao-yang Hospital.

(2)Department of Allergy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.

BACKGROUND: Community-acquired pneumonia (CAP) is a potentially life-threatening condition. The aim of this study is to investigate the stratified and prognostic value of admission lactate and severity scores (confusion, urea >7 mmol/L, respiratory rate ≥30/min, blood pressure <90 mm Hg systolic and/or ≤60 mm Hg diastolic, and age ≥65 years [CURB65], pneumonia severity index [PSI], sequential organ failure assessment [SOFA], qSOFA) in patients with CAP in emergency department.
METHODS: Adult patients diagnosed with CAP admitted between January 2017 and January 2019 were enrolled and divided into severe CAP (SCAP) group and nonSCAP (NSCAP) group according to international guidelines, death group, and survival group according to 28-day prognosis. Predicting performance of parameters above was compared using receiver operating characteristic curves and logistic regression model. Cox proportional hazard regression model was used to identify variables independently associated with 28-day mortality.
RESULTS: A total of 350 patients with CAP were enrolled. About 196 patients were classified as SCAP and 74 patients died after a 28-day follow-up. The levels of CURB65, PSI, SOFA, qSOFA, and admission lactate were higher in the SCAP group and death group. SOFA showed advantage in predicting SCAP, while qSOFA is superior in predicting 28-day mortality. The combination of SOFA and admission lactate outperformed other combinations in predicting SCAP, and the combination of qSOFA and lactate showed highest superiority over other combinations in predicting 28-day mortality.
CONCLUSION: The SOFA is a valuable predictor for SCAP and qSOFA is superior in predicting 28-day mortality. Combination of qSOFA and admission lactate can improve the predicting performance of single qSOFA.

DOI: 10.1097/MD.0000000000017479

PMCID: PMC6799603

PMID: 31593111 [Indexed for MEDLINE]

81. Pediatr Emerg Care. 2019 Oct;35(10):661-665. doi: 10.1097/PEC.0000000000001021.

Evaluation of the Association of Early Elevated Lactate With Outcomes in Children With Severe Sepsis or Septic Shock.

Gorgis N(1), Asselin JM(2), Fontana C(2), Heidersbach RS(3), Flori HR(4), Ward SL(3)(5).

Author information:

(1)From the Department of Pediatrics.

(2)Neonatal-Pediatric Research Group.

(3)Division of Pediatric Critical Care, UCSF Benioff Children's Hospital Oakland, Oakland, CA.

(4)Division of Pediatric Critical Care Medicine, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, MI.

(5)Division of Pediatric Critical Care, UCSF Benioff Children's Hospital San Francisco, CA.

OBJECTIVE: The aim of the study was to assess the association of initial lactate (L0) with mortality in children with severe sepsis.
METHODS: This prospective cohort study included 74 patients younger than 18 years with severe sepsis admitted to the pediatric intensive care unit (PICU) of a tertiary, academic children's hospital with lactate measured within 3 hours of meeting severe sepsis or septic shock. The primary outcome was in-hospital mortality. The secondary outcomes included PICU and hospital length of stay.
RESULTS: Although overall mortality was 10.5% (n = 18), patients with L0 measured (n = 72) had a higher mortality (16% vs 6%, P = 0.03) and higher median PRISM-III risk of mortality scores (P = 0.02) than those who did not. Median L0 was no different between nonsurvivors and survivors (3.6 mmol/L [interquartile range, 2.0-9.0] in nonsurvivors vs 2.3 mmol/L [interquartile range, 1.4-3.5] in survivors, P = 0.11). However, L0 was independently associated with PRISM-III score (coefficient, 1.12; 95% confidence interval, 0.4-1.8; P = 0.003) with an increase in mean PRISM-III score of 1.12 U for every 1 mmol/L increase in L0, with L0 accounting for 12% of the variability in PRISM-III scores between patients. There was no association between L0 and PICU or hospital length of stay.
CONCLUSIONS: Although our single center study did not demonstrate that an elevated early lactate is associated with mortality in pediatric severe sepsis, L0 did correlate strongly with PRISM-III, the most robust measure of mortality risk in pediatrics. Therefore, early lactate measurement may be important as an early biomarker of disease severity. These data should be validated in a larger, multicenter, prospective study.

DOI: 10.1097/PEC.0000000000001021

PMCID: PMC5502202

PMID: 28072671 [Indexed for MEDLINE]

85. 
    Clin Biochem. 2019 Dec;74:47-53. doi:10.1016/j.clinbiochem2019.09.005.Epub 2019 Sep 15

Multilevel qualification of a large set of blood gas analyzers: Which performance goals?

Kuster N(1), Bargnoux AS(1), Badiou S(1), Dupuy AM(2), Piéroni L(2), Cristol JP(3).

Author information:

(1)Department of Biochemistry and Hormonology, CHU de Montpellier, France; PhyMedExp, University of Montpellier, INSERM, CNRS, France.

(2)Department of Biochemistry and Hormonology, CHU de Montpellier, France.

(3)Department of Biochemistry and Hormonology, CHU de Montpellier, France;

PhyMedExp, University of Montpellier, INSERM, CNRS, France.

BACKGROUND: Blood gas analyzers are frequently installed as point of care devices and thus allow rapid decision making. Few data are available regarding analytical performance of large sets of BGA. We aimed at evaluating 22 ABL 90 Flex Plus analyzers intended to be deployed. The evaluation was performed at the device level and at the entire set level to characterize the quality of measurements but also to ensure consistency across the devices deployed in the hospital.
METHODS: Imprecision and total error were assessed for pH, pCO2, pO2, sodium, potassium, ionized calcium, glucose, lactate and oximetry parameters.
Imprecision at the hospital level including between device variability was also evaluated. One of the two analyzers used in the central laboratory was correlated with a GEM Premier 4000 and a Cobas b221 analyzers. Thereafter, we tested sequentially the 20 instruments intended to be deployed in care service in comparison with the reference device.
RESULTS: Heterogeneity of analytical performance across the different analyzers was low, allowing to consider the whole set as a unique analyzer. The total error was in line with performance goals. Analytical performance of the analyzers was found suitable for use in clinical practice.
CONCLUSIONS: Our study is an example of the qualification of a set of point and underscores 1)The need for a unified qualification scheme when multiple analyzers are deployed simultaneously
 2) analytical performance goals compatible with clinical use and the state of the art for all parameters.

DOI: 10.1016/j.clinbiochem.2019.09.005

PMID: 31533025 [Indexed for MEDLINE]

86. 
    Ir Med J. 2019 Sep 12;112(8):992.

Laboratory-Confirmed Metformin-Associated Lactic Acidosis.

Nestor C(1), Nasim S(2), Coyle N(3), Canavan C(4).

Author information:

(1)Specialist Registrar, Irish National Anaesthesia Training Program

(2)Senior Registrar, Department of Anaesthesia, Mayo General Hospital

(3)Graduate Entry Medicine Student, University of Limerick

(4)Consultant Anaesthetist, Department of Anaesthesia, Mayo General Hospital

Introduction Metformin is considered the first line oral hypoglycaemic agent for the treatment of type 2 diabetes. We report three cases of prospectively identified laboratory confirmed metformin-associated lactic acidosis admitted to our intensive care unit.
Case 1 72-year-old female presented with lactic acidosis; pH 6.7, lactate 22.6mmol/L with elevated Metformin levels of 4.9mg/L.
Case 2 56-year-old female presented with lactic acidosis; pH 7.2 and lactate 14.8mmol/L. Metformin levels elevated at 3.9mg/L. Case 3 72-year-old female presented with lactic acidosis, pH 6.95 and lactate of 27.6mmol/L with elevated Metformin levels of 48.7mg/L. Results All three cases were admitted to the intensive care unit to receive supportive care. Despite CVVHD, two patients died. Discussion Metformin is considered the first line oral hypoglycaemic agent. Confirmation of this diagnosis often proves difficult due to the scarcity of laboratory testing. Our case series highlights the issues of inappropriate prescription in specific patient populations.

PMID: 31650826 [Indexed for MEDLINE]

88. 
    Res Q Exerc Sport. 2019 Dec;90(4):678-689. doi: 10.1080/02701367.2019.1643446. Epub 2019 Sep 3.

Lactate Equivalent for Maximal Lactate Steady State Determination in Soccer.

Garcia-Tabar I(1)(2), Rampinini E(3), Gorostiaga EM(1).

Author information:

(1)Government of Navarre.

(2)University of the Basque Country (UPV/EHU).

(3)MAPEI Sport Research Centre.

Purpose: The association between an overlooked classical Lactate Threshold (LT), named "Minimum Lactate Equivalent" (LEmin), with Maximal Lactate Steady State (MLSS) has been recently described with good MLSS prediction results in endurance-trained runners. This study aimed to determine the applicability of LEmin to predict MLSS in lower aerobic-conditioned individuals compared to well-established blood lactate-related thresholds (BLTs). Method: Fifteen soccer players [velocity at MLSS (MLSSV) 13.2 ± 1.0 km·h-1; coefficient of variation (CV) 7.6%] conducted a submaximal discontinuous incremental running test to determine BLTs and 3-6 constant velocity running tests to determine MLSSV.
Results: LEmin did not differ from conventional LTs (p > .05) and was 24% lower than MLSS (p < .001; ES: 3.26). Among LTs, LEmin best predicted MLSSV (r = 0.83; p < .001; SEE = 0.59 km·h-1). There was no statistical difference between MLSS and estimated MLSS using LEmin prediction formula (p = .99; ES: 0.001). Mean bias and limits of agreement were 0.00 ± 0.58 km·h-1 and ±1.13 km·h-1, respectively. LEmin best predicted MLSSV (r = 0.92; p < .001; SEE = 0.54 km·h-1) in the pooled data of soccer players and endurance-trained runners of the previous study (n = 28; MLSSV range 11.2-16.5 km·h-1; CV 9.8%).
Conclusion: Results support LEmin to be one of the best single predictors of MLSS. This study is the sole study providing specific operational regression equations to estimate the impractical gold standard MLSSV in soccer players by means of a BLT measured during a submaximal single-session test.

DOI: 10.1080/02701367.2019.1643446

PMID: 31479401 [Indexed for MEDLINE]

 

92. Pediatr Crit Care Med. 2019 Sep;20(9):e452-e456. doi: 10.1097/PCC.0000000000002074.

Matched Retrospective Cohort Study of Thiamine to Treat Persistent Hyperlactatemia in Pediatric Septic Shock.

Weiss SL, Blowey B(1), Keele L(2), Ganetzky R(3), Murali CN(3), Fitzgerald JC(4)(5), Sutton RM(4), Berg RA(4).

Author information:

(1)Department of Pharmacy, Children's Hospital of Philadelphia, Philadelphia, PA.

(2)Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

(3)Division of Human Genetics, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

(4)Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

(5)Pediatric Sepsis Program at the Children's Hospital of Philadelphia, Philadelphia, PA.

Comment in  Pediatr Crit Care Med. 2019 Sep;20(9):903-904.

OBJECTIVES: Thiamine deficiency may propagate lactate production by limiting pyruvate dehydrogenase activity, and studies suggest benefit for thiamine administration in septic adults. We studied the effect of thiamine on physiologic and clinical outcomes for children with septic shock and hyperlactatemia.
DESIGN: Retrospective matched cohort study.
SETTING: Single academic PICU.
PATIENTS: Six thiamine-treated cases and nine matched controls.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: The primary outcome was change in blood lactate from prethiamine (T0, cases) or maximum (T0, controls) lactate through 24 hours later (T24). Secondary outcomes were change in lactate over 48 hours (T48) and 72 hours (T72), time to lactate normalization, changes in vasoactive-inotrope score, organ dysfunction severity (daily Pediatric Logistic Organ Dysfunction 2 score), and creatinine, PICU length of stay, and hospital mortality. Lactate was greater than 5 mmol/L for a median of 39 hours (range, 16.1-64.3 hr) prior to thiamine administration for cases compared with 3.4 hours (range, 0-22.9 hr) prior to maximum lactate for controls (p = 0.002). There was no difference in median (interquartile range) change in lactate from T0 to T24 between thiamine-treated cases and controls (-9.0, -17.0 to -5.0 vs -7.2, -9.0 to -5.3 mmol/L, p = 0.78), with both groups exhibiting a rapid decrease in lactate. There were also no differences in secondary outcomes between groups.
CONCLUSIONS: Treatment of pediatric septic shock with thiamine was followed by rapid improvement in physiologic and clinical outcomes after prolonged hyperlactatemia. Although we are not able to infer that thiamine provided benefit over usual care, the rapid decline in lactate after thiamine despite a prolonged period of hyperlactatemia raises the possibility that thiamine helped to reverse lactate production.

DOI: 10.1097/PCC.0000000000002074

PMCID: PMC6726577

PMID: 31274776 [Index