Blood lactate levels and its association with survival outcome in polytrauma patients

Abstract               Background: Lactate as a marker for tissue hypoperfusion is an established biomarker for morbidity and mortality in patients with sepsis and trauma, but has limited clinical application. Aim of this study is was significant (P<0.001) as compared to 2.8 in survivor. The mean blood lactate level in non to evaluate serial serum lactate levels and its association with mortality of the patients of traumatic injury admitted in trauma centre. Many studies have confirmed relationship between tissue hypoxia and generation of lactate. Reflecting the level of tissue hypoxia, we examined the relationship between blood lactate level and survival rate. Materials and Methods: After the admission of patients of traumatic injury (n=63) in the trauma centre and the establishment of diagnosis, for the evaluation of serial blood lactate levels, we have collected the sample at the time of admission, 12 hours, 24 hours, and 36 hours subsequently. Comparison of two means between survivor and non survivor was performed using unpaired student t test. Results: Out of 63 patients 5 were non survivor and 58 were survivor. The mean blood lactate level in non-survivor was 5.9 at the time of admission, which -survivor was 2.7 after 36 hours, which was also significant (P<0.001) as compared to 0.98 among survivor. Conclusion: Blood lactate level at the time of admission and lactate clearance during the initial hours of admission can be a good predictor of patient’s morbidity and mortality. However, some of our patients with elevated initial lactate values recovered well, probably due to better treatment

Key Word: Clinical Biochemistry, Polytrauma, Lactate level.

INTRODUCTION

Trauma is the third leading cause of death worldwide, mainly affecting the young population. Road traffic accident is the main cause for the largest number of traumatic patients. Around the world every day, around 3000 people die from injuries resulting from traffic accidents. These especially affect the 15–29 year-old age group, according with WHOreports.¹ It is thought that serum lactate levels help in predicting outcome of the patients who are severely ill or injured and in-hospital monitoring of serial lactate levels has been shown to be a good predictor of injury severity and outcome following trauma.² The government of India has initiated a programme under ICMR to study health of the nation’s states, under which the disease burden profile of Gujarat state data was collected between 1990-2016 showing trauma is a public health problem, where traumatic injuries due to violence and traffic accidents are the common causes of morbidity and mortality.³ Therefore, there is a need for a biomarker that allows us to quickly and reliably assess the diagnostic process of hypo- perfusion during its early stage, in order to take the pertinent steps to reduce these mortality figures. This why lactate represents an important tool within this scenario, being a widely studied biomarker. ^4,5,6 The metabolic response occurring after the traumatic injuries are mainly due to inadequate supply of oxygen, hypoxia and anaerobic metabolism, leads to accumulation of lactate. It results from the metabolism of pyruvate catalyzed by the enzyme lactate dehydrogenase, found in high concentrations in trauma patients due to shock .^7,8,9 Some studies have linked lactate >4 mmol/l as a major criterion of severity and chance of survival.¹⁰ Others show that patients with high blood lactate have higher risk of death compared to those with levels within the normal laboratory range. The clearance of lactate may represent good parameter to analyze the quality of resuscitation measures in trauma and information on prognosis, especially in early mortality. The main advantages of monitoring blood lactate concentrations as an indicator of metabolic derangements are sensitivity and accuracy about tissue perfusion, simple performance and rapid availability of results. Thus, the lactate can be used as a good predictor of injury severity and outcome following trauma.^11,12,13

MATERIALS AND METHODS

The prospective observational study was conducted in GMERS Medical College and Hospital, Sola Gujarat. We have included 63 patients, both male/female in the age group between 18 to 60 years old admitted in the trauma centre within 12 hours of trauma including road traffic accidents, fall from height, and assault. We have excluded the patients having Co morbidities like bronchial asthma, diabetes, ischemic heart disease, congestive heart failure, renal failure, renal transplant, malignancy, chronic pancreatitis, History of acute alcohol ingestion, ingestion of poison, Known inborn error of lactate metabolism. Blood Sample collection: for the evaluation of serial blood lactate levels, we have collected the sample at the time of admission, 12 hours, 24 hours, and 36 hours subsequently. The outcome was recorded as survival or non-survival. A record of the number of days of hospital and ICU stay was also kept after inclusion into the study. We have estimated the lactate level in instrumentation Laboratory (ILAB) GEM Premium 2000 ABG analyzer. Mean and standard deviations were calculated for each variable. Comparison of two means was performed using unpaired student t test.

RESULTS OBSERVATION AND DISCUSSION

Table 1: Sex distribution in the study

Figure 1: showing age distribution in the study

Table 2: Unpaired t test results

The two tailed P value is less than 0.0001 at the 95% confidence interval. t= 4.9774 , df = 61, standard error of difference = 0.630

Table 3: Unpaired t test results

The two tailed P value is less than 0.0001 at the 95% confidence interval. t= 4.3073, df = 59, standard error of difference = 0.398 During the study period, 63 trauma patients were admitted to our trauma center. Blood lactate was measured at the time of admission in 63 patients (100%). Therefore, data from all 63 patients were retained for analysis. Out of 63 patients 15 (23%) have blood lactate level > 4 milimole/liter at the time of admission. from these 15 patients 5 patients were non survive which indicate 33% mortality among the patients having blood lactate level >4 milimole/ liter. Out of total 63 patients 05 patients were non survivor and 58 were survivor . Our study shows that the mean blood lactate level in non-survivor was 5.9 at the time of admission, which was significantly higher as compared to 2.8 in survivor (table no 2). It was found that lactate level after 36 hours time point were significantly higher in non survivors as compared survivors (table no 3). Our results show that for all patients presenting to the trauma centre due to multiple trauma, a rising lactate value was associated with a higher mortality. Our finding were in keeping with the current literature describing the predictive ability of initial lactate level on in- hospital morltality.^14,15,16 Henry oliveros-rodriguez et al studied Lactate serial measurements and predictive validity of early mortality in trauma patients admitted in the ICU and concluded that lactic acid was associated with mortality at seven days in three time measurement.¹⁷ Lamichhane Et al Studied In serum lactate – an indicator of morbidity and mortality in polytrauma patients concluded that blood lactate appears to be a reliable marker reflecting not only the severity of shock, but also for predicting survival. The longer the lactate is elevated, the more a patients is likely to develop multiple organ dysfunctions and die. Lactate levels followed over time is more reliable than isolated values.¹⁸

CONCLUSION

Serum lactate at the time of admission and lactate clearance at 12 hours can be a very good prognostic factor in predicting the morbidity and mortality in polytrauma. Though some of our patients with elevated initial lactate values recovered well, probably due to better resuscitation, normal lactate values at the time of admission can be a useful means to identify low-risk trauma patients. Similarly, very high lactate at the time of admission strongly predicted mortality in our study, although more sample size is needed to demonstrate the association

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