title: A hypoperfusion context may aid to interpret hyperlactatemia in sepsis-3 septic shock patients: a proof-of-concept study.
abstract: BACKGROUND
  Persistent hyperlactatemia is particularly difficult to interpret in septic shock. Besides hypoperfusion, adrenergic-driven lactate production and impaired lactate clearance are important contributors. However, clinical recognition of different sources of hyperlactatemia is unfortunately not a common practice and patients are treated with the same strategy despite the risk of over-resuscitation in some. Indeed, pursuing additional resuscitation in non-hypoperfusion-related cases might lead to the toxicity of fluid overload and vasoactive drugs. We hypothesized that two different clinical patterns can be recognized in septic shock patients through a multimodal perfusion monitoring. Hyperlactatemic patients with a hypoperfusion context probably represent a more severe acute circulatory dysfunction, and the absence of a hypoperfusion context is eventually associated with a good outcome. We performed a retrospective analysis of a database of septic shock patients with persistent hyperlactatemia after initial resuscitation.
  
  
  RESULTS
  We defined hypoperfusion context by the presence of a ScvO2< 70%, or a P(cv-a)CO2≥6 mmHg, or a CRT ≥4 s together with hyperlactatemia. Ninety patients were included, of whom seventy exhibited a hypoperfusion-related pattern and 20 did not. Although lactate values were comparable at baseline (4.8 ± 2.8 vs. 4.7 ± 3.7 mmol/L), patients with a hypoperfusion context exhibited a more severe circulatory dysfunction with higher vasopressor requirements, and a trend to longer mechanical ventilation days, ICU stay, and more rescue therapies. Only one of the 20 hyperlactatemic patients without a hypoperfusion context died (5%) compared to 11 of the 70 with hypoperfusion-related hyperlactatemia (16%).
  
  
  CONCLUSIONS
  Two different clinical patterns among hyperlactatemic septic shock patients may be identified according to hypoperfusion context. Patients with hyperlactatemia plus low ScvO2, or high P(cv-a)CO2, or high CRT values exhibited a more severe circulatory dysfunction. This provides a starting point to launch further prospective studies to confirm if this approach can lead to a more selective resuscitation strategy.
authors.affiliation: Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago, 8320000, Chile.
authors.forename: Leyla
authors.initials: L
authors.lastname: Alegría
authors.affiliation: Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago, 8320000, Chile.
authors.forename: Magdalena
authors.initials: M
authors.lastname: Vera
authors.affiliation: Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago, 8320000, Chile.
authors.forename: Jorge
authors.initials: J
authors.lastname: Dreyse
authors.affiliation: Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago, 8320000, Chile.
authors.forename: Ricardo
authors.initials: R
authors.lastname: Castro
authors.affiliation: Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago, 8320000, Chile.
authors.forename: David
authors.initials: D
authors.lastname: Carpio
authors.affiliation: Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago, 8320000, Chile.
authors.forename: Carolina
authors.initials: C
authors.lastname: Henriquez
authors.affiliation: Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago, 8320000, Chile.
authors.forename: Daniela
authors.initials: D
authors.lastname: Gajardo
authors.affiliation: Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago, 8320000, Chile.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Bravo
authors.affiliation: Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago, 8320000, Chile.
authors.forename: Felipe
authors.initials: F
authors.lastname: Araneda
authors.affiliation: Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago, 8320000, Chile.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Kattan
authors.affiliation: Hospital San Francisco, Quito, Ecuador.
authors.forename: Pedro
authors.initials: P
authors.lastname: Torres
authors.affiliation: Intensive Care Medicine Department, Fundación Valle del Lili - Universidad ICESI, Cali, Colombia.
authors.forename: Gustavo
authors.initials: G
authors.lastname: Ospina-Tascón
authors.affiliation: Assistance Publique-Hôpitaux de Paris, Hôpitaux universitaires Paris-Sud, Hôpital de Bicêtre, Service de Réanimation Médicale, Le Kremlin-Bicêtre, France.
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Teboul
authors.affiliation: Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago, 8320000, Chile.|Department of Intensive Care Adults, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Jan
authors.initials: J
authors.lastname: Bakker
authors.affiliation: Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago, 8320000, Chile. glenn@med.puc.cl.
authors.forename: Glenn
authors.initials: G
authors.lastname: Hernández
keywords: Capillary refill time; Central venous oxygen saturation; Central venous-arterial PCO2 gradient; Hyperlactatemia; Hypoperfusion; Resuscitation; Septic shock