Point of care lactate for differentiating septic shock from hypovolemic shock in non-ICU settings: a prospective observational study

IF 5 Q1 HEALTH CARE SCIENCES & SERVICES The Lancet regional health. Southeast Asia Pub Date : 2024-10-21 DOI:10.1016/j.lansea.2024.100500
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Abstract

Background

Septic shock and hypovolemic shock are life-threatening illnesses that necessitate immediate recognition and intervention, as they can result in deadly consequences. While the underlying processes may vary, both entities can exhibit hypotension and organ dysfunction. No studies have been conducted on bedside testing to differentiate between these illnesses. Lactate measurement has been established as a viable option for early detection of septic shock. However, its role in diagnosing hypovolemic shock has yet to be evaluated. The aim of the study was to investigate alterations in lactate levels among diarrheal patients with septic shock and hypovolemic shock following the administration of first fluid resuscitation.

Methods

We conducted a prospective observational study in critically ill diarrheal adults aged ≥18 years in the emergency ward in Dhaka Hospital of icddr,b from 21st October 2021 to 31st May 2023 (total 19 months). The enrollment process was operational between 8:30 AM and 5:00 PM. Diarrheal adults with a diagnosis of sepsis with shock featured with poor peripheral perfusion (characterized by cold periphery and weak or absent pulse and capillary refill time >3 s) or hypotension (characterized by mean arterial pressure <65 mm-Hg) were enrolled as cases and consecutive diarrheal patients without any obvious features of sepsis with hypovolemic shock (due to severe dehydration) comprised the comparison group. POC lactate test was done at hours 0, 1st and 6th by StatStrip Lactate meters (Nova Biomedical, US) to all enrolled patients. For comparison of POC lactate levels, we used paired t-test for comparing the lactate samples drawn at hour 0, hour 1 and 6 with the septic shock and hypovolemic shock group. Odds ratio (OR) and their 95% confidence intervals (CIs) were used to demonstrate the strength of association. The study was registered at Clinicaltrials.gov (NCT05108467) and received institutional ethical approval (PR-21097).

Findings

Of 435 patients, 135 had septic shock and 141 had hypovolemic shock, rest 41 patient responded with fluid bolus. 25% (34/135) of the people in the septic shock group died whereas there is no mortality in the hypovolemic shock group. The number of patients visiting from outside Dhaka city had more septic shock than from inside were higher in comparison with (55% vs. 28%; p < 0.001). Statistically significant difference was observed between septic shock and hypovolemic shock group for a median POC lactate in 0, 1st and 6th hours with an OR of 1.07 (95% CI: 0.99, 1.17; p = 0.039); 1.48, (95% CI: 1.28, 1.70; p < 0.001) and 2.36 (95% CI: 1.85, 3.00; p < 0.001), respectively. The gradient of 1st to 2nd sample between septic shock and hypovolemic shock was found to be significantly different (OR: 0.74, 95% CI: 0.64, 0.85; p < 0.001).

Interpretation

POC lactate test can detect septic shock by differentiating hypovolemic shock in diarrheal patients. By providing quick, reliable and accurate result this test can help clinicians quickly diagnose and treat time-sensitive condition, like septic shock.

Funding

The study was funded by Global Affairs of Canada (GR-01726). The donors had no role in the design, implementation, analysis, data interpretation or writing manuscript, or decision to publish. The corresponding author had access to all data and takes responsibility for the final approval and submission of the manuscript.
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在非重症监护病房环境中,护理点乳酸可用于区分脓毒性休克和低血容量休克:一项前瞻性观察研究
背景败血性休克和低血容量性休克是危及生命的疾病,需要立即识别和干预,因为它们可能导致致命后果。虽然其基本过程可能各不相同,但这两种疾病都会表现出低血压和器官功能障碍。目前还没有研究通过床旁检测来区分这两种疾病。乳酸测量已被确定为早期检测脓毒性休克的可行方法。然而,它在诊断低血容量性休克方面的作用还有待评估。本研究旨在调查脓毒性休克和低血容量性休克腹泻患者在接受首次液体复苏后乳酸水平的变化。报名时间为上午 8:30 至下午 5:00。诊断为脓毒症伴休克的成人腹泻患者以外周灌注不足(表现为外周发冷、脉搏微弱或消失、毛细血管再充盈时间为 3 秒)或低血压(表现为平均动脉压为 65 mm-Hg)为病例,无明显脓毒症特征的连续腹泻患者以低血容量休克(由于严重脱水)为对比组。所有入组患者均在第 0、1 和 6 小时使用 StatStrip 乳酸测量仪(Nova Biomedical,美国)进行了 POC 乳酸测试。为了比较 POC 乳酸水平,我们使用配对 t 检验法比较了脓毒性休克组和低血容量休克组在第 0 小时、第 1 小时和第 6 小时抽取的乳酸样本。用比值比(OR)及其 95% 置信区间(CI)来证明关联的强度。该研究已在 Clinicaltrials.gov 注册(NCT05108467),并获得了机构伦理批准(PR-21097)。脓毒性休克组中有 25% (34/135)的患者死亡,而低血容量性休克组则无死亡病例。达卡市外就诊的患者中,脓毒性休克患者人数高于达卡市内就诊的患者人数(55% vs. 28%; p <0.001)。脓毒性休克组和低血容量休克组在 0 小时、1 小时和 6 小时的 POC 乳酸中位数有明显统计学差异,OR 分别为 1.07(95% CI:0.99,1.17;p = 0.039)、1.48(95% CI:1.28,1.70;p <;0.001)和 2.36(95% CI:1.85,3.00;p <;0.001)。脓毒性休克和低血容量性休克之间的第 1 次样本到第 2 次样本的梯度有显著差异(OR:0.74,95% CI:0.64,0.85;p <;0.001)。通过提供快速、可靠和准确的结果,该测试可帮助临床医生快速诊断和治疗脓毒性休克等时间敏感性疾病。捐赠者未参与设计、实施、分析、数据解读或撰写手稿,也未决定是否发表。通讯作者可获得所有数据,并对稿件的最终批准和提交负责。
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