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      Aclaramiento de lactato en trauma penetrante grave Translated title: Lactate clearance in severe penetrating trauma

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          Abstract

          Resumen Introducción: El trauma es una de las principales causas de muerte en el mundo. La reacción metabólica culmina con una inadecuada entrega de oxígeno y metabolismo anaerobio, y el producto final es el lactato. Las altas concentraciones de lactato al ingreso del paciente y una normalización lenta o incompleta, se asocian con mayor mortalidad. Materiales y métodos: Se llevó a cabo un estudio prospectivo de cohorte, de junio de 2016 a noviembre de 2017, de pacientes mayores de 18 años con trauma penetrante grave, sometidos a cirugía emergente y con posquirúrgico en la unidad de cuidados intensivos. Se evaluaron algunos puntajes de gravedad y se cuantificó el lactato al ingreso y a las 6, 12, 18 y 24 horas. Las variables de resultados fueron: mortalidad, tiempo de estancia hospitalaria e infección del sitio operatorio. Se hizo un análisis bivariado y se elaboró un modelo de regresión lineal múltiple para estimar las asociaciones. Resultados: Se incluyeron 130 pacientes, entre los cuales hubo 8 (6,2 %) muertes. No hubo asociación entre la depuración del lactato y la incidencia de infección del sitio operatorio (ISO). En los fallecidos, los valores absolutos de lactato al ingreso fueron significativamente mayores que en los demás, y se observó tendencia a una menor depuración en 24 horas; después de 12 horas del ingreso, la depuración del lactato fue de más del 50 % en los sobrevivientes y, en los fallecidos, de 25,7 %. En más de la mitad de los pacientes, no se depuró el 50 % del valor inicial de lactato a las 6, 12 o 24 horas. Conclusión: Se demuestra la utilidad de hacer seguimiento de la concentración de lactato sérico en las primeras 24 horas, pues sirve como un factor pronóstico en pacientes con trauma penetrante grave.

          Translated abstract

          Abstract Introduction: Trauma is one of the main causes of death worldwide. The metabolic response culminates with inadequate oxygen delivery and anaerobic metabolism, the final product being lactate. High lactate levels at admission and slow or incomplete return to normal values are associated with higher mortality. Materials and methods: Prospective cohort study in patients older than 18 years with severe penetrating trauma taken to emergent surgery and post-surgery in intensive or especial care unit in the period June 2016 to November 2017. Some severity scores and lactate values were determined at admission, and at 6, 12, 18 and 24 hours. The outcome variables were mortality, length of hospital stay and surgical site infection. To estimate the associations we used a bivariate analysis and a multiple linear regression model. Results: 130 patients were included, registering 8 deaths (6.2%). There was no association between lactate clearance and incidence of surgical site infection. Absolute lactate values at admission were significantly higher in the deceased; a tendency to a lower percentage of clearance was recorded in the deceased at 24 hours; at 12 hours after admission, the survivors had a clearance of more than 50% of the lactate and the deceased 25.7%. More than half of the patients did not clear 50% of the initial value of lactate at 6, 12 and 24 hours. Conclusion: The usefulness of lactate monitoring during the first 24 hours as a prognostic factor in patients with severe penetrating trauma is demonstrated.

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          Early lactate clearance is associated with improved outcome in severe sepsis and septic shock.

          Serial lactate concentrations can be used to examine disease severity in the intensive care unit. This study examines the clinical utility of the lactate clearance before intensive care unit admission (during the most proximal period of disease presentation) as an indicator of outcome in severe sepsis and septic shock. We hypothesize that a high lactate clearance in 6 hrs is associated with decreased mortality rate. Prospective observational study. An urban emergency department and intensive care unit over a 1-yr period. A convenience cohort of patients with severe sepsis or septic shock. Therapy was initiated in the emergency department and continued in the intensive care unit, including central venous and arterial catheterization, antibiotics, fluid resuscitation, mechanical ventilation, vasopressors, and inotropes when appropriate. Vital signs, laboratory values, and Acute Physiology and Chronic Health Evaluation (APACHE) II score were obtained at hour 0 (emergency department presentation), hour 6, and over the first 72 hrs of hospitalization. Therapy given in the emergency department and intensive care unit was recorded. Lactate clearance was defined as the percent decrease in lactate from emergency department presentation to hour 6. Logistic regression analysis was performed to determine independent variables associated with mortality. One hundred and eleven patients were enrolled with mean age 64.9 +/- 16.7 yrs, emergency department length of stay 6.3 +/- 3.2 hrs, and overall in-hospital mortality rate 42.3%. Baseline APACHE II score was 20.2 +/- 6.8 and lactate 6.9 +/- 4.6 mmol/L. Survivors compared with nonsurvivors had a lactate clearance of 38.1 +/- 34.6 vs. 12.0 +/- 51.6%, respectively (p =.005). Multivariate logistic regression analysis of statistically significant univariate variables showed lactate clearance to have a significant inverse relationship with mortality (p =.04). There was an approximately 11% decrease likelihood of mortality for each 10% increase in lactate clearance. Patients with a lactate clearance> or =10%, relative to patients with a lactate clearance <10%, had a greater decrease in APACHE II score over the 72-hr study period and a lower 60-day mortality rate (p =.007). Lactate clearance early in the hospital course may indicate a resolution of global tissue hypoxia and is associated with decreased mortality rate. Patients with higher lactate clearance after 6 hrs of emergency department intervention have improved outcome compared with those with lower lactate clearance.
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            Lactate clearance and survival following injury.

            Previous reports cite optimization of O2 delivery (DO2) to 660 mL/min/m2, O2 consumption (VO2) to 170 mL/min/m2, and cardiac index (CI) of 4.5 L/min as predicting survival. We prospectively evaluated 76 consecutive patients with multiple trauma admitted directly to the ICU from the operating room or emergency department. Patients had serum lactate levels and oxygen transport measured on ICU admission and at 8, 16, 24, 36, and 48 hours. Patients were analyzed with respect to survival (S) versus nonsurvival (NS), lactate clearance to normal (< or = 2 mmol/L) by 24 and 48 hours, hemodynamic optimization as defined above, as well as Injury Severity Score (ISS), ICU stay (LOS), and admission blood pressure. All patients achieved non-flow-dependent VO2. There was no difference in CI, DO2, VO2, or ISS when S was compared with NS. All 27 patients whose lactate level normalized in 24 hours survived. If lactate levels cleared to normal between 24 and 48 hours, the survival rate was 75%. Only 3 of the 22 patients who did not clear their lactate level to normal by 48 hours survived. Ten of the 25 nonsurvivors (40%) achieved the above arbitrary optimization criteria. Fifteen of the survivors never achieved any of these criteria. Optimization alone does not predict survival. However, the time needed to normalize serum lactate levels is an important prognostic factor for survival in severely injured patients.
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              Lactate clearance is a useful biomarker for the prediction of all-cause mortality in critically ill patients: a systematic review and meta-analysis*.

              Lactate clearance has been widely investigated for its prognostic value in critically ill patients. However, the results are conflicting. The present study aimed to explore the diagnostic accuracy of lactate clearance in predicting mortality in critically or acutely ill patients. Databases of Medline, Embase, Scopus, and Web of Knowledge were searched from inception to June 2013. Studies investigating the prognostic value of lactate clearance were defined as eligible. The searched item consisted of terms related to critically ill patients and terms related to lactate clearance. The following data were extracted: the name of the first author, publication year, subjects and setting, mean age of study population, sample size, male percentage, mortality of study cohort, definition of clearance, and the initial lactate level. Relative risk was reported to estimate the predictive value of lactate clearance on mortality rate, with relative risk less than 1 indicating that lactate clearance was a protective factor. Meta-analysis of diagnostic accuracy of lactate clearance in predicting mortality was performed by using hierarchical summary receiver operating characteristic model. A total of 15 original articles were included in the study. Because of the significant heterogeneity across studies (I = 61.4%), random-effects model was used to pool relative risks. The pooled relative risk for mortality was 0.38 (95% CI, 0.29-0.50). The overall sensitivity and specificity for lactate clearance to predict mortality were 0.75 (95% CI, 0.58-0.87) and 0.72 (95% CI, 0.61-0.80), respectively. The diagnostic performance improved slightly when meta-analysis was restricted to ICU patients, with sensitivity and specificity of 0.83 (95% CI, 0.67-0.92) and 0.67 (95% CI, 0.59-0.75), respectively. Our study demonstrates that lactate clearance is predictive of lower mortality rate in critically ill patients, and its diagnostic performance is optimal for clinical utility.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Role: ND
                Journal
                rcci
                Revista Colombiana de Cirugía
                rev. colomb. cir.
                Asociación Colombiana de Cirugía (Bogotá, Distrito Capital, Colombia )
                2011-7582
                2619-6107
                December 2018
                : 33
                : 4
                : 380-389
                Affiliations
                [1] Medellín Antioquía orgnameUniversidad de Antioquia Colombia
                [3] Medellín orgnameHospital Universitario de San Vicente Fundación Colombia
                [2] Medellín orgnameHospital Universitario de San Vicente Fundación Colombia
                Article
                S2011-75822018000400380
                10.30944/20117582.85
                e0e7023a-3efb-4aae-9434-0aa5fe792008

                This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

                History
                : 08 June 2018
                : 21 August 2018
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 20, Pages: 10
                Product

                SciELO Colombia

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                Artículos originales

                ácido láctico,tasa de depuración,heridas y traumatismos,heridas penetrantes,mortalidad,infección de la herida quirúrgica,lactic acid,clearance rate,wounds and injuries,wounds,penetrating,mortality,surgical wound infection

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