Objectives: This study aimed to compare the prognostic value of lactate level and lactate clearance at 6 hours after septic shock recognition. And, we performed it to determine lactate kinetics in the Sepsis-3 defined septic shock. Design: This retrospective study was performed from a prospective septic shock registry. Settings: This study was performed at single urban tertiary center. And, all patients were treated with protocol-driven resuscitation bundle therapy between 2010 and 2016. Patients: We included septic shock patients who met the Sepsis-3 definition, which involves lactate levels greater than or equal to 2 mmol/L and vasopressor use. Interventions: Serum lactate levels were measured at initial and 6 hours from septic shock recognition. Measurements and Main Results: Lactate clearance was calculated as ([initial lactate – 6-hr lactate]/initial lactate) × 100. The prognostic value of measured lactate levels and lactate clearance for 28-day mortality was analyzed and compared with that of subsequent lactate levels greater than or equal to 2 mmol/L, greater than or equal to 3 mmol/L, and greater than or equal to 4 mmol/L and less than 10%, less than 20%, and less than 30% lactate clearance. A total of 1,060 septic shock patients by Sepsis-3, 265 patients died (28-d mortality: 25%). In survivor, groups had lower median 6-hour lactate level and higher lactate clearance than nonsurvivors (2.5 vs 4.6 mmol/L and 35.4% vs 14.8%; p < 0.01). Both lactate and lactate clearance were associated with mortality after adjusting for confounders (odd ratio, 1.27 [95% CI, 1.21–1.34] and 0.992 [95% CI, 0.989–0.995]), but lactate had a significantly higher prognostic value than lactate clearance (area under the curve, 0.70 vs 0.65; p < 0.01). The prognostic value of subsequent lactate levels (≥ 2, ≥ 3, and ≥ 4 mmol/L) and lactate clearances (< 10%, < 20%, and < 30%) was not significantly differed. However, lactate levels of greater than or equal to 2 mmol/L had the greatest sensitivity (85.3%). Conclusions: Our findings indicate lactate and lactate clearance are both useful targets in patients with septic shock defined by Sepsis-3. Serum lactate level at 6-hour can be an easier and more effective tool for prognosis of septic shock patients who were treated with protocol-driven resuscitation bundle therapy.

Aim: The aim of this study was to evaluate the clinical utility of the lactate/albumin (L/A) ratio as a predictive factor of 28-day mortality in critically ill sepsis patients. Methods: This is a retrospective observational study from a prospectively collected multicenter registry of 10 emergency departments (EDs) in teaching hospitals that participated in the Korean Shock Society. It enrolled patients who were 19 years of age or older who had a suspected or confirmed infection and evidence of refractory hypotension or hypoperfusion. The prognostic performance of the L/A ratio and lactate level for predicting 28-day mortality was assessed. Lactate and albumin levels were measured immediately after ED arrival. Results: A total of 946 patients were included, with 22.5% overall 28-day mortality. The area under the receiver operating characteristic curve (AUROC) value of the L/A ratio (0.69, 95% confidence interval [CI] 0.64–0.73, P < 0.01) was higher than that of lactate (0.65, 95% CI 0.61–0.70, P < 0.01) for predicting 28-day mortality. The optimal cutoff of the L/A ratio was 1.32. The AUROC value of the L/A ratio was better than that of lactate regardless of lactate level (normal [<2.0 mmol/L]: 0.68 vs. 0.55; intermediate [≥2.0, < 4.0 mmol/L]: 0.65 vs. 0.50; high [≥4.0 mmol/L]: 0.66 vs. 0.62). In the subgroup with decreased lactate elimination, the AUROC value of the L/A ratio was also significantly higher than that of lactate (hepatic dysfunction: 0.70 vs. 0.66; renal dysfunction: 0.71 vs. 0.67). The L/A ratio cut-off and hypoalbminemia showed further discriminative value for 28-day mortality even in patients with normal or intermediate lactate levels. Conclusions: The prognostic performance of the L/A ratio was superior to that of a single lactate measurement for predicting 28-day mortality of critically ill sepsis patients. L/A ratio can be a useful prognostic factor regardless of initial lactate level and the presence of hepatic or renal dysfunction.

The aim of this study was to determine whether initial shock index (SI) was independently associated with the requirement for massive transfusion (MT) in emergency department (ED) patients with primary postpartum hemorrhage (PPH). A retrospective cohort study of ED patients with primary PPH was performed at a university-affiliated, tertiary referral center between January 2004 and May 2012. Patients were classified to two groups: MT group (patients who received ≥10 U of packed red blood cells within 24 h of ED admission) and non-MT group (patients who received <10 U). Variables of the two groups were compared using univariate and multivariate analyses. A total of 126 patients were included in this study. Of these patients, 26 (20.6%) were included in MT group and 100 (79.4%) in non-MT group. Patients in MT group had significantly lower blood pressure and higher heart rate compared with patients in non-MT group (P < 0.01). Initial SI was significantly higher in MT group than in non-MT group (1.3 vs 0.8, P < 0.01). In multivariate logistic regression analysis, initial SI and heart rate were the only variables associated with the requirement for MT, with an odds ratio of 9.47 (95% confidence interval, 1.75–51.28; P < 0.01) and 1.06 (95% confidence interval, 1.02–1.09; P < 0.01), respectively. In conclusion, initial SI was independently associated with the requirement for MT in ED patients with primary PPH. Routine calculation of initial SI can help clinicians to identify patients who may benefit from timely and appropriate use of MT to improve clinical outcomes.

Many comatose patients following cardiac arrest have ischemic brain injury. Diffusion-weighted imaging is a sensitive tool to identify hypoxic-ischemic brain injury. The accurate prediction of the prognosis for comatose cardiac arrest survivors has been challenging, and thus, a multimodal approach, combining diffusion-weighted image findings, could be feasible. The aim of this study was to assess regional brain injury on diffusion-weighted imaging and to test the potential association with its neurologic outcome in patients treated with target temperature management after out-of-hospital cardiac arrest. A multicenter, registry-based, retrospective cohort study was conducted using cases from 24 hospitals across South Korea. Of the 930 adult (≥ 18 yr) nontraumatic out-of-hospital cardiac arrest patients treated with target temperature management between January 2007 and December 2012 at these hospitals, we included the patients who underwent brain diffusion-weighted imaging in the first week after cardiac arrest. The brain regions examined included the four cerebral lobes, basal ganglia-thalamus, brain stem, and cerebellum. Imaging results were compared between a good neurologic outcome, defined as a cerebral performance category score of 1 or 2, and a poor neurologic outcome (cerebral performance category score ≥ 3). Poor neurologic outcome occurred in 118 of the 172 patients analyzed (68.6%). Positive diffusion-weighted image findings, defined as any regional brain injury lesion in diffusion-weighted imaging, were present in 106 patients. Positive diffusion-weighted image findings had 93% sensitivity, 86% specificity, 76% positive predictive value, and 96% negative predictive value for a poor neurologic outcome. The poor outcome group had higher numbers of affected brain lesions than the good outcome group (3.8 ± 1.9 vs 0.1 ± 0.6; p < 0.01). By multivariate analysis, positive diffusion-weighted image findings (odds ratio, 58.2; 95% CI, 13.29–254.91) and lack of a shockable rhythm (odds ratio, 0.13; 95% CI, 0.03–0.57) were associated with a poor neurologic outcome. Diffusion-weighted imaging allows reliable prediction of poor neurologic outcome in comatose patients treated with target temperature management after out-of-hospital cardiac arrest. Further prospective validation study will be required to generalize this result.