title: Hyperlactatemia is an independent predictor of mortality and denotes distinct subtypes of severe sepsis and septic shock.
abstract: OBJECTIVE
  Current guidelines and most trials do not consider elevated lactate (Lac) serum concentrations when grading sepsis severity. We therefore assessed the association of different types of circulatory dysfunction regarding presence of hyperlactatemia and need for vasopressor support with clinical presentation and outcome of sepsis.
  
  
  METHODS
  In a secondary analysis of a prospective observational multicenter cohort study, 988 patients with severe sepsis were investigated regarding vasopressor support, Lac levels, and outcome.
  
  
  RESULTS
  Twenty-eight-day mortality regarding shock or hyperlactatemia was as follows: hyperlactatemia more than 2.5 mmol/L and septic shock (tissue dysoxic shock): 451 patients with a mortality of 44.8%; hyperlactatemia without vasopressor need (cryptic shock): 72 patients, mortality 35.3%; no hyperlactatemia with vasopressor need (vasoplegic shock): 331 patients, mortality 27.7%; and absence of hyperlactemia or overt shock (severe sepsis): 134 patients, mortality 14.2% (P < .001). These groups showed differences in source and origin of infection. The influence of hyperlactatemia on 28-day mortality (P < .001) (odds ratio 3.0, 95% confidence interval 2.1-4.1 for Lac >4 mmol/L) was independent of vasopressor support (P < .001) (odds ratio 2.0, 95% confidence interval 1.3-3.0 for norepinephrine >0.1 μg/kg per minute) in logistic regression.
  
  
  CONCLUSIONS
  Hyperlactatemia increases risk of death independent of vasopressor need resulting in different phenotypes within the classic categories of severe sepsis and septic shock.
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany; The Integrated Research and Treatment Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany. Electronic address: daniel.thomas@med.uni-jena.de.
authors.forename: Daniel O
authors.initials: DO
authors.lastname: Thomas-Rueddel
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.
authors.forename: Bernhard
authors.initials: B
authors.lastname: Poidinger
authors.affiliation: Department of Anesthesiology, University Hospital Ulm, Ulm, Germany.
authors.forename: Manfred
authors.initials: M
authors.lastname: Weiss
authors.affiliation: Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Ev. Krankenhaus Bielefeld, Bielefeld, Germany.
authors.forename: Friedhelm
authors.initials: F
authors.lastname: Bach
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, Bundeswehrkrankenhaus Berlin, Berlin, Germany.
authors.forename: Karin
authors.initials: K
authors.lastname: Dey
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Tübingen, Germany.
authors.forename: Helene
authors.initials: H
authors.lastname: Häberle
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany.
authors.forename: Udo
authors.initials: U
authors.lastname: Kaisers
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany; The Integrated Research and Treatment Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.
authors.forename: Hendrik
authors.initials: H
authors.lastname: Rüddel
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Germany.
authors.forename: Dirk
authors.initials: D
authors.lastname: Schädler
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, Ernst-Moritz-Arndt-University Greifswald, Greifswald, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Scheer
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, Zentralklinik Bad Berka GmbH, Bad Berka, Germany.
authors.forename: Torsten
authors.initials: T
authors.lastname: Schreiber
authors.affiliation: Department of Intensive Care Medicine, University Hospital Aachen, Aachen, Germany.
authors.forename: Tobias
authors.initials: T
authors.lastname: Schürholz
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany.
authors.forename: Philipp
authors.initials: P
authors.lastname: Simon
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, Bundeswehrkrankenhaus Berlin, Berlin, Germany.
authors.forename: Armin
authors.initials: A
authors.lastname: Sommerer
authors.affiliation: The Integrated Research and Treatment Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.
authors.forename: Daniel
authors.initials: D
authors.lastname: Schwarzkopf
authors.affiliation: Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine, and Pain Therapy, Hospital Oldenburg, Oldenburg, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Weyland
authors.affiliation: Department of Intensive Care Medicine, HELIOS Klinikum Wuppertal, Wuppertal, Germany.
authors.forename: Gabriele
authors.initials: G
authors.lastname: Wöbker
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany; The Integrated Research and Treatment Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.
authors.forename: Konrad
authors.initials: K
authors.lastname: Reinhart
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany; The Integrated Research and Treatment Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.
authors.forename: Frank
authors.initials: F
authors.lastname: Bloos
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D005260:Female; D006801:Humans; D065906:Hyperlactatemia / Q000097:blood*; D019344:Lactic Acid / Q000097:blood*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009638:Norepinephrine / Q000627:therapeutic use; D016017:Odds Ratio; D011379:Prognosis; D011446:Prospective Studies; D018805:Sepsis / Q000097:blood / Q000188:drug therapy / Q000401:mortality; D012772:Shock, Septic / Q000097:blood* / Q000188:drug therapy / Q000401:mortality; D014662:Vasoconstrictor Agents / Q000627:therapeutic use
chemical_list: D014662:Vasoconstrictor Agents; D019344:Lactic Acid; D009638:Norepinephrine
keywords: Critical care; Lactic acid; Sepsis; Septic shock