Lactate predicts massive transfusion in hemodynamically normal patients

doi:10.1016/j.jss.2016.04.015

Journal of Surgical Research

Volume 204, Issue 1, July 2016, Pages 139-144

https://doi.org/10.1016/j.jss.2016.04.015 Get rights and content

Abstract

Background

Trauma patients at risk of deterioration because of occult injury may be hemodynamically normal on arrival. Early identification of these patients may improve care, especially for those who require massive transfusion (MT). We hypothesized that elevated admission lactate would predict the need for MT in hemodynamically normal patients.

Materials and methods

All trauma patients treated at our university-based urban center over a 5-year period were reviewed. We included hemodynamically normal patients who had an admission lactate performed. First, a receiver-operating curve was used to determine the threshold lactate value. Subsequent analyses were then based on this value. Variables were analyzed using chi-square and unpaired t-tests, and univariable and multivariable regressions.

Results

There were 3468 hemodynamically normal patients with an admission lactate. Those who received MT (n = 19) had higher lactate than those who did not (n = 3449; 5.6 versus 2.6 mmol/L, P ≤ 0.001). Receiver-operating curve curve analysis revealed a threshold lactate value of 4 mmol/L with an area under the curve of 0.71. Patients with a lactate of >4 mmol/L had increased mortality (8% versus 2%), longer hospital length of stay (LOS, 6 versus 3 days), longer intensive care unit (ICU) LOS (6 versus 3 days), greater need for MT (2.8% versus 0.3%), and greater blood requirement (219 versus 38 mL; all P values < 0.001). After controlling for confounding variables, the predictive value of admission lactate >4 remained strong (odds ratio, 5.2; 95% confidence interval, 1.87-14.2).

Conclusions

In hemodynamically normal trauma patients, the admission lactate of >4 mmol/L is a robust predictor of MT requirement and associated with poor outcomes.

Introduction

Early identification of seriously injured trauma patients is crucial. Some patients may arrive appearing hemodynamically normal, but they may have occult injuries and may suddenly deteriorate. Early identification of which patients may suddenly deteriorate may improve patient care.¹ This may be especially true for those who will require a massive transfusion (MT), since blood products are often a scarce resource and blood product preparation takes time.²

Early lactate measurement may help predict poor outcomes, especially in patients in shock or with multisystem organ failure.3, 4, 5, 6, 7, 8, 9, 10, 11 However, there are few studies focusing on the relationship between admission lactate (lactate) and the need for MT.¹² Important, to our knowledge, there are no studies that characterize a relationship between lactate and MT in hemodynamically normal patients; therefore, the utility of lactate in these patients is unknown.

To further investigate the role of an early lactate value in this patient population, our hypothesis was that an elevated admission lactate predicts the need for MT in hemodynamically normal trauma patients. Our specific aims were: (1) to determine if an elevated admission lactate corresponds to the need for MT in hemodynamically normal trauma patients, (2) to determine if there is a threshold lactate level that predicts the need for MT, (3) to examine the effect of a threshold lactate level on patient outcomes, and (4) to examine the strength of lactate as a predictor of MT.

Section snippets

Materials and methods

This study received institutional approval and complied with human research protocols. All trauma patients treated at our university-based urban trauma center over a 5-year period were reviewed. Included were hemodynamically normal patients who received an admission lactate level. Minors, pregnant women, prisoners, patients with incomplete records, and those who were dead on arrival were excluded.

Hemodynamically normal was defined as having both a systolic blood pressure (SBP) >90 mm Hg and a

Results

During the study period, we treated 10,336 trauma patients, of whom 5951 were hemodynamically normal on arrival. Of the hemodynamically normal patients, 3468 (58%) had an admission lactate and met entrance criteria. The baseline characteristics of those hemodynamically normal patients who did and did not receive an admission lactate are listed in Table 1.

Of the 3468 patients who were both hemodynamically stable and had an admission lactate drawn, those who received an MT (n = 19) had a higher

Discussion

Our ability to provide appropriate and timely patient care in trauma can be a challenge because of the acute nature of traumatic events, with patients arriving unexpectedly or with little notice. To provide adequate care, anticipation of a patient's clinical course is important, as is the availability and allocation of necessary resources. One group of trauma patients who are especially vulnerable are those in “compensated shock”; patients who have sustained substantial injuries but who are

Acknowledgment

All of the listed authors were involved in the collection of data, analysis of data, and production of the article. L.Y. and G.P.V. were responsible for study conception and design. M.A.B. and G.P.V. were responsible for final editing of the article and submission.

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Lactate levels were significantly higher in nonsurvivors than in survivors [19-22]. Furthermore, elevated blood lactate levels predicted major haemorrhage and increased blood transfusion requirements [23,24]. Most importantly, the need for operative intervention was associated with lactate levels [22,25].
Surgery is usually suggested to treat massive haemothorax (MHT). The MHT criteria are based on penetrating trauma observations in military scenarios; the need for surgery in blunt trauma patients remains questionable. This study aimed to determine the characteristics of blunt trauma patients with MHT who required surgery.
Patients who presented to the emergency department (ED) with traumatic haemothorax or pneumothorax, heart and lung injuries, and thoracic blood vessel injuries from Jan 1, 2014, to Dec 31, 2018, were reviewed. The inclusion criterion was a chest tube drainage amount that met the MHT criteria. Therapeutic operations were defined as those involving surgical haemostasis; otherwise, operations were considered non-therapeutic. The non-therapeutic operation group included the patients who received nonoperative management. The characteristics of the therapeutic and non-therapeutic operation groups were compared.
Forty-four patients were enroled in the study. Six patients received conservative treatment and were discharged uneventfully. Eleven patients underwent non-therapeutic operations. The patients with surgical bleeding had a high pulse rate (125.0 (111.0, 135.0) vs. 116.0 (84.0, 121.0) bpm, p = 0.013); low systolic blood pressure (SBP) after resuscitation (106.0 (84.0, 127.0) vs. 121.0 (116.0, 134.0) mmHg, p = 0.040); low pH (7.2 (7.2, 7.3) vs. 7.4 (7.3, 7.4), p = 0.002); and low bicarbonate (17.8 (14.6, 21.5) vs. 21.4 (17.0, 21.5) mEq/L, p = 0.038), low base excess (-9.1 (-13.4, -4.5) vs. -3.8 (-10.1, -0.7), p = 0.028), and high lactate (5.7 (3.3, 7.8) vs. 1.8 (1.7, 2.8) mmol/L, p = 0.002) levels.
Conservative treatment could be performed selectively in patients with MHT. Lactate could be a predictor of the need for surgical intervention in blunt trauma patients with MHT.
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Patients with liver disease and those with renal failure who required dialysis were excluded because these diseases may impair lactate clearance [30,31]. Patients with trauma who received massive transfusion were also excluded because lactate levels would be variable during resuscitation with massive transfusion [32,33]. Some of the confounding factors associated with lactate clearance such as mean arterial pressure, central venous pressure, central venous O2 saturation, hemoglobin, antibiotics treatment and acid–base status were not included due to the retrospective nature of the study.
Patients with sepsis have significant mortality and morbidity that may improve by normalization of lactate as indication of adequate resuscitation. We sought to quantify the volume of fluid associated with correction of lactate in septic surgical patients.
A retrospective review was conducted in all patients with elevated lactate who were admitted to the SICU at a Level I trauma center from February 2016 to April 2018. Patients ≥18 years with sepsis, septic shock, infection, and lactate >2.5 mmol/l with subsequent lactate follow up were included. Patients on dialysis, liver failure, and trauma patients who received massive transfusion were excluded. Data was collected on patients’ demographics, hospital length of stay (LOS), mortality and volume of fluid given. The primary outcome was the volume of fluid required to correct lactate by 1 mmol/l. Pearson correlation coefficient was calculated to evaluate the association between fluid volume and lactate level.
Forty-eight patients were included. The mean age was 67 (14.2) years, 56.3% were males, and mortality was 22%. The mean elevated lactate was 4.90 (3.02) mmol/l. An average of 1372 (1809) cc of fluid was needed to reduce lactate by 1 mmol/l. The average time for correction was 5.2 (5.6) hours. There was weak correlation between resuscitation fluid volume and lactate correction (r = 0.29, p = 0.05).
About 1400 cc of fluid was required to correct the lactate by 1 mmol/l. This value can help guide resuscitation in septic surgical patients. The weak correlation between resuscitation fluid volume and lactate correction highlights the importance of other interventions including the early administration antibiotics and source control.
Blood lactate concentration and shock index associated with massive transfusion in emergency department patients with primary postpartum haemorrhage
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In this regard, two studies on trauma patients have been reported.13,14 According to a study by Brooke and colleagues,13 lactate is a better predictor concerning blood requirements in trauma patients compared with systolic BP. Another study reported that a lactate concentration of >4 mM L−1 upon admission is a robust predictor of massive transfusion requirement in haemodynamically normal trauma patients.14
We hypothesised that lactate concentrations are independently associated with massive transfusion in patients with primary postpartum haemorrhage. Moreover, combining lactate concentrations with the shock index, defined as the ratio of heart rate to systolic arterial blood pressure, can improve the predictive performance for massive transfusion.
We retrospectively analysed patients with primary postpartum haemorrhage in the emergency department of a tertiary referral centre in Korea between January 1, 2004 and December 31, 2015.
Of the 302 patients, 101 (33.4%) patients required massive transfusion. Lactate concentration was independently associated with the requirement for massive transfusion [odds ratio, 1.56; 95% confidence interval (CI), 1.31–1.87; P<0.01]. The area under the receiver operating characteristic curve of lactate concentration and shock index for massive transfusion was 0.788 (95% CI: 0.736–0.840; P<0.01) and 0.776 (95% CI: 0.717–0.836; P<0.01), respectively. Lactate elevation (>4.0 mM L⁻¹) was associated with 86.1% specificity and 67.8% positive predictive value for massive transfusion. When combining elevated lactate concentrations (>4.0 mM L⁻¹) with a shock index >1.0, the specificity and positive predictive value increased to 95.5% and 82.4%, respectively.
Point-of-care testing of lactate concentrations in the emergency department may be useful to predict massive transfusion requirements in primary postpartum haemorrhage. Combining initial lactate concentrations with the shock index improves the predictive performance for massive transfusion requirements and may contribute to rapid risk stratification of patients with primary postpartum haemorrhage in need of transfusion and further focus on early interventions to control bleeding.
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In this study, we found that the GCS and positive FAST finding are important clinical findings for predicting the need for pRBC transfusion. Previous reports mentioned the relationship between the GCS and massive blood transfusion; however, the authors did not mention the details [4,12]. Smith et al. [13] mentioned the relationship between blood transfusion and GCS in pediatric patients with trauma.
To find factors that predict the requirement of packed red blood cells (pRBC) transfusion in patients with blunt trauma on arrival at the hospital.
We conducted blood tests in trauma patients whose trauma severity was suspected as being 3 and over in the Abbreviated Injury Scale. Patients were divided into the blood transfusion (BT) and control groups according to the requirement of pRBC transfusion within 24 h after arrival.
We analyzed 347 patients (BT group, n = 14; control group, n = 333). On univariate analysis, there were significant differences in Glasgow Coma Scale (GCS), rate of positive FAST (focused assessment with sonography for trauma) finding, hematocrit, international normalized ratio of prothrombin time, activated partial thromboplastin time, fibrinogen (Fib), and level of fibrin degradation products (FDP). On multivariable analysis, positive FAST finding, GCS, Fib, and FDP influenced the requirement of pRBC transfusion. In the area under the receiver operating characteristic curve analysis, Fib and FDP were markers that predicted the requirement of pRBC transfusion. The FDP/Fib ratio had a better correlation with the requirement of pRBC transfusion than FDP or Fib.
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Shock/Sepsis/Trauma/Critical CareLactate predicts massive transfusion in hemodynamically normal patients

Abstract

Background

Materials and methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Results

Discussion

Acknowledgment

Clin Chim Acta

Am J Emerg Med

J Am Coll Surg

J Emerg Med

Chest

J Am Coll Surg

Am J Surg

Burns

Am J Surg

Resuscitation endpoints

J Trauma

Creation, implementation, and maturation of a massive transfusion protocol for exsanguinating trauma patient

J Trauma

Lactate clearance and survival following injury

J Trauma

The golden hour and the silver day: detection and correction of occult hypoperfusion within 24 hours improves outcome from major trauma

J Trauma

Excess lactate: an index of reversibility of shock in human patients

Science

Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial

Am J Respir Crit Care Med

Association between blood lactate levels, Sequential Organ Failure Assessment subscores, and 28-day mortality during early and late intensive care unit stay: a retrospective observational study

Crit Care Med

Occult hypoperfusion is associated with increased mortality in hemodynamically stable, high-risk, surgical patients

Crit Care

Serial lactate determinations during circulatory shock

Crit Care Med

Acs Surgery: Principles & Practice

Shock/Sepsis/Trauma/Critical Care
Lactate predicts massive transfusion in hemodynamically normal patients