Journal Article

Early Lactate-Guided Therapy in Intensive Care Unit Patients: A Multicenter, Open-Label, Randomized Controlled Trial

Sleeswijk Visser, Steven J., Willemsen, Sten P., Schoonderbeek, F. Jeanette, van Bommel, Jasper, Jansen, Tim C., van der Klooster, Johan M., Bakker, Jan, Lima, Alex P.

2010

Overview

Abstract Rationale It is unknown whether lactate monitoring aimed to decrease levels during initial treatment in critically ill patients improves outcome. Objectives To assess the effect of lactate monitoring and resuscitation directed at decreasing lactate levels in intensive care unit (ICU) patients admitted with a lactate level of greater than or equal to 3.0 mEq/L. Methods Patients were randomly allocated to two groups. In the lactate group, treatment was guided by lactate levels with the objective to decrease lactate by 20% or more per 2 hours for the initial 8 hours of ICU stay. In the control group, the treatment team had no knowledge of lactate levels (except for the admission value) during this period. The primary outcome measure was hospital mortality. Measurements and Main Results The lactate group received more fluids and vasodilators. However, there were no significant differences in lactate levels between the groups. In the intention-to-treat population (348 patients), hospital mortality in the control group was 43.5% (77/177) compared with 33.9% (58/171) in the lactate group (P = 0.067). When adjusted for predefined risk factors, hospital mortality was lower in the lactate group (hazard ratio, 0.61; 95% confidence interval, 0.43–0.87; P = 0.006). In the lactate group, Sequential Organ Failure Assessment scores were lower between 9 and 72 hours, inotropes could be stopped earlier, and patients could be weaned from mechanical ventilation and discharged from the ICU earlier. Conclusions In patients with hyperlactatemia on ICU admission, lactate-guided therapy significantly reduced hospital mortality when adjusting for predefined risk factors. As this was consistent with important secondary endpoints, this study suggests that initial lactate monitoring has clinical benefit. Clinical trial registered with www.clinicaltrials.gov (NCT00270673).

• Publisher: Oxford University Press,American Thoracic Society
• Subject: Aged / Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy / Biological and medical sciences / Biomarkers - blood / Clinical death. Palliative care. Organ gift and preservation / Consent / Critical Care - methods / Critical Illness - mortality / Critical Illness - therapy / Female / Hospital Mortality / Humans / Intensive care / Intensive care medicine / Intensive Care Units / Kaplan-Meier Estimate / Lactic Acid - blood / Length of Stay - statistics & numerical data / Male / Medical sciences / Metabolism / Middle Aged / Mortality / Patients / Proportional Hazards Models / Risk Factors / Sepsis / Time Factors / Treatment Outcome / Ventilators