Lactate ClearanceAs a predictor of mortality in trauma patients

Reno Rudiman

Why do we need predictor?

2

• Important in clinical uncertainty

• Mis-inference may result in an increased risk of an adverse event

• Avoiding unnecessary cost of care

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Why do we need predictor?

Mortality of trauma

4

Mortality of trauma

• 10% of all deaths are caused by trauma (Maegel 2010)

• In Indonesia 2011, there were 108.696 traffic accidents, of which 31.195 dead (BPS, 2011)

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Lactate

• End product of anaerobic metabolism

• Marker for cellular hypoxia in shock

• Early identification of severe injury

Lactate clearance

• Rapid clearance of lactate is associated with improved outcome in septic shock & critically ill

• Is it a better indicator for ongoing tissue hypoperfusion?

• Better guide for resuscitation?

Lactate clearance

Lactate clearance = ([Lactateinitial – Lactatedelayed]/ Lactateinitial) × 100 × Delay−1 (expressed as %/h)

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Admission Lactate

died

survived

0

1.5

3

4.5

6

Pal JD, et al. J Trauma 2006; 60: 583-589

Initial lactate: survivors vs nonsurvivors

10Pal JD, et al. J Trauma 2006; 60: 583-589

Admission Lactate

Although mean admission lactate was significantly lower in survivors than nonsurvivors, the overlap between the groups was so great that little ability to discriminate survivors from non-survivors is apparent

11Pal JD, et al. J Trauma 2006; 60: 583-589

SBP on mortality

12Odom et al. J Trauma Acute Care Surg 2013; 74(4): 999-1004

Survival probability

13Odom et al. J Trauma Acute Care Surg 2013; 74(4): 999-1004

Relationship of lactate and ISS values in 5,995 trauma patients

14Pal JD, et al. J Trauma 2006; 60: 583-589

Lactate on mortality

Odom et al. J Trauma Acute Care Surg 2013; 74(4): 999-1004

Lactate on mortality

16Regnier, et al. Anesthesiology 2012; 71(6): 1276-1288

17Regnier, et al. Anesthesiology 2012; 71(6): 1276-1288

Lactate on mortality

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initial p=0,356

post p<0,01

0

0.55

1.1

1.65

2.2

successful failed

Successful vs failed Non Operative management in blunt abdominal trauma

Haryatama, Rudiman, Sulthana. In publication, 2012.

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lactate pre vs post

lactate pre vs BE pre

latate post vs BE post

BE pre vs post

lactate diff vs BE diff

-0.7 -0.35 0 0.35 0.7 1.05

Failed Successful

Haryatama, Rudiman, Sulthana. In publication, 2012.

Successful vs failed Non Operative management in blunt abdominal trauma

Mortality according to initial blood lactate level and/or lactate clearance (n = 453)

20Regnier, et al. Anesthesiology 2012; 71(6): 1276-1288

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Conclusion

• Lactate clearance provides additional predictive information to initial blood lactate levels and scores

• Lactate clearance is a useful prognostic variable in trauma patients.

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