Published online Jun 6, 2023. doi: 10.12998/wjcc.v11.i16.3765
Peer-review started: November 30, 2022
First decision: January 17, 2023
Revised: January 17, 2023
Accepted: April 18, 2023
Article in press: April 18, 2023
Published online: June 6, 2023
Processing time: 183 Days and 17.5 Hours
As per the latest Surviving Sepsis Campaign guidelines, fluid resuscitation should be guided by repeated measurements of blood lactate levels until normalization.
Serum lactate is a non-specific biomarker that may be increased by a myriad of clinical conditions. Thus, it may not be the best tool for real-time assessment of the effect of hemodynamic resuscitation, and exploring alternative resuscitation targets should be an essential research priority in sepsis.
To compare the 28-d mortality in two clinical patterns of septic shock: hyperlactatemic patients in the hypoperfusion context and hyperlactatemic patients in the non-hypoperfusion context.
This prospective comparative observational study carried out on 135 adult patients with septic shock that met Sepsis-3 definitions compared patients of hyperlactatemia with hypoperfusion (Group 1, n = 95) and hyperlactatemia without hypoperfusion (Group 2, n = 40). The patients were observed for various macro and micro hemodynamic parameters at regular intervals of 0 h, 3 h, and 6 h. All-cause 28-d mortality and all other secondary objective parameters were observed at specified intervals.
The stratification of patients into hypoperfusion and non-hypoperfusion did not result in a significantly different 28-d mortality (24% vs 15%, respectively; P = 0.234). However, the patients within the hypoperfusion context with high P(cv-a)CO2 and CRT (P = 0.022) at baseline had significantly higher mortality than Group 2. Group 1 had a higher proportion of patients requiring vasopressin and the mean vasopressor-free days out of the total 28 d were lower in patients with hypoperfusion (18.88 ± 9.04 vs 21.08 ± 8.76; P = 0.011). The mean lactate levels and lactate clearance at 3 h and 6 h, CRT, and P(cv-a)CO2 at 0 h, 3 h, and 6 h were found to be associated with 28-d mortality in patients with septic shock, with lactate levels at 6 h having the best predictive value (area under the receiver operating characteristic: 0.845).
Septic shock patients fulfilling the hypoperfusion and non-hypoperfusion context exhibit similar 28-d all-cause hospital mortality, although patients with hypoperfusion displayed a more severe circulatory dysfunction. Lactate levels at 6 h had a better predictive value in predicting 28-d mortality. Persistently high P(cv-a)CO2 (> 6 mmHg) or increased CRT (> 4 s) at 3 h and 6 h during the early resuscitation can be a valuable additional aid for prognostication of septic shock patients.
Multicenter large scale trials should be conducted to further evaluate the role of CRT and PCO2 gap as markers for resuscitation in patients with septic shock.