Scientific Letter
Toward a personalized response approach in sepsis 4.0
Hacia una estrategia de respuesta personalizada en sepsis 4.0
C. de Haroa, E. Torrentsa, R. Ferrerb, A. Artigasa, A. Rodriguezc, I. Martin-Loechesd,
Corresponding author
a Critical Care Center, Parc Taulí Hospital-Sabadell, CIBERes, Parc Tauli s/n. Sabadell, Barcelona, Spain
b Critical Care Center, Vall d’Hebron Hospital, CIBERes, Pss Villanova s/n, Barcelona, Spain
c Critical Care Department, Joan XXIII University Hospital, CIBERes, Dr. Mallafrè Guasch, 4, Tarragona, Spain
d Multidisciplinary Intensive Care Research Organization (MICRO), CIBERes, Wellcome Trust HRB Clinical Research, Department of Clinical Medicine, Trinity Centre for Health Sciences, St James's University Hospital, St James's Street, Dublin, Ireland
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Sabadell, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Critical Care Center, Vall d’Hebron Hospital, CIBERes, Pss Villanova s/n, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Critical Care Department, Joan XXIII University Hospital, CIBERes, Dr. Mallafrè Guasch, 4, Tarragona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Multidisciplinary Intensive Care Research Organization (MICRO), CIBERes, Wellcome Trust HRB Clinical Research, Department of Clinical Medicine, Trinity Centre for Health Sciences, St James's University Hospital, St James's Street, Dublin, Ireland" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hacia una estrategia de respuesta personalizada en sepsis 4.0" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 779 "Ancho" => 1622 "Tamanyo" => 45466 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Odds ratio for mortality in patients included in the study. <span class="elsevierStyleItalic">Abbreviation</span>: OR, odds ratio.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Sepsis is one of the leading causes of mortality worldwide.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> However, mortality rates widely vary among different countries when patients have been enrolled in prospective septic shock trials.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> For this and other reason, including sepsis recognition, new definitions of septic shock were launched. Now, shock is a clinical condition defined by a vasopressor requirement to maintain a mean arterial pressure of 65<span class="elsevierStyleHsp" style=""></span>mm Hg or greater and serum lactate level greater than 2<span class="elsevierStyleHsp" style=""></span>mmol/L (>18<span class="elsevierStyleHsp" style=""></span>mg/dL) in the absence of hypovolemia.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Our hypothesis is that lactate level is not sufficient for defining shock progression but timing within the first 24<span class="elsevierStyleHsp" style=""></span>h of resuscitation. The aim of the present study is to determine the prognostic value of a predefined lactate clearance in the first 24<span class="elsevierStyleHsp" style=""></span>h of sepsis. A total of 544 consecutive patients with sepsis were included from a tertiary University Hospital (Parc Tauli Hospital, Sabadell, Spain). The vast majority presented an abdominal (37.9%) or respiratory source of sepsis (31.3%) and 62.8% were admitted through emergency department. Patients presented were 66.6 (SD 14.8) years old, 63.2% male and presented an APACHE II score of 18.4 (SD 7.7) with a mortality rate of 29.8%. We calculated the optimal cutoff for a lower mortality during the first 24<span class="elsevierStyleHsp" style=""></span>h of sepsis using the Youden index. With our data, this optimal cutoff was 10%, with a sensitivity of 51% and specificity of 71%. Patients with a lactate clearance<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>10% within the first 24<span class="elsevierStyleHsp" style=""></span>h of sepsis had a lower mortality in a univariate analysis than patients without that clearance (21.2% vs. 39.1%; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). We adjusted lactate clearance for confounding factors, as initial lactate value and severity (APACHE II score), and we observed that lactate clearance<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>10% during the first 24<span class="elsevierStyleHsp" style=""></span>h of sepsis was identified as a protective factor for mortality (OR 0.49: 95% CI 0.30–0.81; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). We, therefore, analyzed the relationship between lactate clearance and the fulfillment of the Surviving Sepsis Campaign (SSC) bundles. The group of patients with a lactate clearance<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>10% trended toward a better fulfillment of SCC bundles (5.1% vs. 2.2%; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.12). We performed a multivariate analysis including all the SCC bundles (antibiotic treatment, fluid administration, vasopressors and initial lactate value and fluid administration) and lactate clearance<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>10% (OR 6.41; 95% CI 2.01–20.45; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05) was associated independently with a lower mortality. Despite the new incorporation of serum lactate levels for shock definition, we consider that the most important approach to reflect current ICU mortality would be the use of lactate clearance in the definition.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Therefore, a personalized approach is lacking in the current definitions and a lactate clearance equal or greater than 10% within the first 24<span class="elsevierStyleHsp" style=""></span>h of sepsis evolution is independently associated with lower mortality. Nguyen et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> discovered that early lactate clearance within the first 6<span class="elsevierStyleHsp" style=""></span>h was associated with a decrease mortality however the 10% decrease was chosen after analyzing sensitivity and specificity of different thresholds. In our study, the implementation of a mathematical model (Youden index) helped us to find the “ideal threshold”. Interestingly, in accordance with recently published studies, in our cohort, fluid administration during the first hours of sepsis is independently associated with lactate clearance.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> Effort should be done to identify patients with shock and determinant of response, rather than to flag them only shocked.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0010" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0015" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to disclose.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 779 "Ancho" => 1622 "Tamanyo" => 45466 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Odds ratio for mortality in patients included in the study. <span class="elsevierStyleItalic">Abbreviation</span>: OR, odds ratio.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of severe sepsis: advances, challenges, and current status" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "I. 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De Backer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00134-015-3906-y" "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med" "fecha" => "2015" "volumen" => "41" "paginaInicial" => "1620" "paginaFinal" => "1628" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26109396" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000004100000001/v1_201703040056/S2173572717300127/v1_201703040056/en/main.assets" "Apartado" => array:4 [ "identificador" => "15647" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735727/0000004100000001/v1_201703040056/S2173572717300127/v1_201703040056/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572717300127?idApp=WMIE" ]
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| 2022 December | 74 | 30 | 104 |
| 2022 November | 78 | 52 | 130 |
| 2022 October | 96 | 44 | 140 |
| 2022 September | 88 | 41 | 129 |
| 2022 August | 80 | 40 | 120 |
| 2022 July | 49 | 34 | 83 |
| 2022 June | 72 | 33 | 105 |
| 2022 May | 57 | 37 | 94 |
| 2022 April | 46 | 59 | 105 |
| 2022 March | 47 | 50 | 97 |
| 2022 February | 60 | 32 | 92 |
| 2022 January | 36 | 33 | 69 |
| 2021 December | 61 | 44 | 105 |
| 2021 November | 45 | 35 | 80 |
| 2021 October | 60 | 74 | 134 |
| 2021 September | 34 | 27 | 61 |
| 2021 August | 28 | 47 | 75 |
| 2021 July | 35 | 30 | 65 |
| 2021 June | 26 | 41 | 67 |
| 2021 May | 49 | 47 | 96 |
| 2021 April | 80 | 117 | 197 |
| 2021 March | 50 | 28 | 78 |
| 2021 February | 48 | 35 | 83 |
| 2021 January | 41 | 26 | 67 |
| 2020 December | 32 | 17 | 49 |
| 2020 November | 34 | 26 | 60 |
| 2020 October | 34 | 30 | 64 |
| 2020 September | 84 | 20 | 104 |
| 2020 August | 33 | 13 | 46 |
| 2020 July | 54 | 15 | 69 |
| 2020 June | 30 | 14 | 44 |
| 2020 May | 19 | 10 | 29 |
| 2020 April | 22 | 15 | 37 |
| 2020 March | 28 | 17 | 45 |
| 2020 February | 44 | 36 | 80 |
| 2020 January | 29 | 22 | 51 |
| 2019 December | 39 | 19 | 58 |
| 2019 November | 31 | 29 | 60 |
| 2019 October | 36 | 17 | 53 |
| 2019 September | 34 | 23 | 57 |
| 2019 August | 40 | 24 | 64 |
| 2019 July | 36 | 19 | 55 |
| 2019 June | 10 | 17 | 27 |
| 2019 May | 28 | 20 | 48 |
| 2019 April | 26 | 19 | 45 |
| 2019 March | 21 | 29 | 50 |
| 2019 February | 14 | 22 | 36 |
| 2019 January | 23 | 32 | 55 |
| 2018 December | 17 | 40 | 57 |
| 2018 November | 84 | 31 | 115 |
| 2018 October | 54 | 21 | 75 |
| 2018 September | 29 | 8 | 37 |
| 2018 August | 49 | 4 | 53 |
| 2018 July | 17 | 4 | 21 |
| 2018 June | 18 | 8 | 26 |
| 2018 May | 10 | 4 | 14 |
| 2018 April | 16 | 3 | 19 |
| 2018 March | 21 | 3 | 24 |
| 2018 February | 9 | 4 | 13 |
| 2018 January | 28 | 12 | 40 |
| 2017 December | 17 | 5 | 22 |
| 2017 November | 13 | 6 | 19 |
| 2017 October | 14 | 5 | 19 |
| 2017 September | 18 | 10 | 28 |
| 2017 August | 10 | 16 | 26 |
| 2017 July | 14 | 6 | 20 |
| 2017 June | 19 | 12 | 31 |
| 2017 May | 15 | 8 | 23 |
| 2017 April | 24 | 0 | 24 |
| 2017 March | 0 | 1 | 1 |
Show all
