Targeting Lactate Clearance Improves ICU Outcomes

Targeting lactate clearance levels improves mortality and shortens intensive care unit (ICU) stay, according to a new study.

Researchers at Erasmus MC University (Rotterdam, The Netherlands), Reinier de Graaf Hospital (Delft, The Netherlands) conducted a multicenter randomized study to assess the effect of lactate monitoring and treatment directed at decreasing lactate levels in ICU patients that were admitted with a lactate level equal or higher than 3.0 mEq/L. A total of 348 patients were randomly allocated to two groups; in the lactate group (171 patients), treatment was guided by lactate levels with the objective of decreasing lactate by at least 20% per two hours for the initial eight hours of ICU stay. In the control group (177 patients), the treatment team had no knowledge of lactate levels (except for the admission value) during this period. The primary outcome measure was hospital mortality.

The results of the study showed that hospital mortality in the control group was higher (43.5%) compared with the lactate group (33.9%), even after adjustment for predefined risk factors. The patients in the lactate group received significantly more fluids than did control group patients, and more patients in the lactate group received vasodilator therapy. Similar proportions of patients in the lactate and control groups received mechanical ventilation, antibiotics, corticosteroids, additional surgery following ICU admission, analgesics, sedatives, therapeutic hypothermia, and a percutaneous coronary intervention (PCI). The researchers also found that in the lactate group, Sequential Organ Failure Assessment (SOFA) scores were lower between 9 and 72 hours, inotropes could be stopped earlier, and the patients could be weaned from mechanical ventilation and discharged from the ICU earlier. The study was published in the May 2010 issue of American Journal of Respiratory and Critical Care Medicine.

"In patients with hyperlactatemia on ICU admission, lactate-guided therapy significantly reduced hospital mortality when adjusting for predefined risk factors,” concluded lead author Jan Bakker, M.D., and colleagues of the ICU. "As this was consistent with important secondary endpoints, this study suggests that initial lactate monitoring has clinical benefit.”

The treatment algorithm suggested by the study begins with continuous monitoring of central venous hemoglobin oxygen saturation (ScvO2), so as to balance oxygen delivery with demand. When ScvO2 was at least 70%, but lactate clearance targets were not being met, the patients received vasodilators with the goal of improving microvascular perfusion. Before administering the vasodilator infusions, the researchers also checked fluid responsiveness and gave fluids as necessary.

Related Links:
Erasmus MC University
Reinier de Graaf Hospital