Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial.
BACKGROUND
It is unknown whether lactate monitoring aimed to decrease levels during initial treatment in critically ill patients improves outcome.


OBJECTIVE
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.


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).
Jansen
Tim C
TC
Department of Intensive Care, Erasmus MC University Medical Centre, Rotterdam, The Netherlands.
van Bommel
Jasper
J
Schoonderbeek
F Jeanette
FJ
Sleeswijk Visser
Steven J
SJ
van der Klooster
Johan M
JM
Lima
Alex P
AP
Willemsen
Sten P
SP
Bakker
Jan
J
D000368:Aged; D015415:Biomarkers / Q000097:blood; D003422:Critical Care / Q000379:methods*; D016638:Critical Illness / Q000401:mortality / Q000628:therapy*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D053208:Kaplan-Meier Estimate; D019344:Lactic Acid / Q000097:blood*; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
D015415:Biomarkers; D019344:Lactic Acid