Observational Study
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Jun 6, 2023; 11(16): 3765-3779
Published online Jun 6, 2023. doi: 10.12998/wjcc.v11.i16.3765
Hypoperfusion context as a predictor of 28-d all-cause mortality in septic shock patients: A comparative observational study
Sahil Kataria, Omender Singh, Deven Juneja, Amit Goel, Madhura Bhide, Devraj Yadav
Sahil Kataria, Omender Singh, Deven Juneja, Amit Goel, Madhura Bhide, Devraj Yadav, Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
Author contributions: Kataria S, Singh O, and Juneja D designed the study; Kataria S, Bhide M, and Yadav D collected the data and analyzed the results; Kataria S and Juneja D performed the majority of the writing and prepared the tables; Singh O, Goel A, Devraj Y, and Bhide M provided input in writing the paper and reviewed the manuscript; All authors read and approved the final manuscript.
Institutional review board statement: The study was reviewed and approved by the Max Super Specialty Hospital, Saket, Institutional Review Board (Approval No. TS/MSSH/MHIL/SKT-1/MHEC/CC/20-14).
Conflict-of-interest statement: The authors declare no conflicts of interest.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Deven Juneja, DNB, Director, Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, 1, Press Enclave Road, New Delhi 110017, India. devenjuneja@gmail.com
Received: November 30, 2022
Peer-review started: November 30, 2022
First decision: January 17, 2023
Revised: January 17, 2023
Accepted: April 18, 2023
Article in press: April 18, 2023
Published online: June 6, 2023
Research background

As per the latest Surviving Sepsis Campaign guidelines, fluid resuscitation should be guided by repeated measurements of blood lactate levels until normalization.

Research motivation

Serum lactate is a non-specific biomarker that may be increased by a myriad of clinical conditions. Thus, it may not be the best tool for real-time assessment of the effect of hemodynamic resuscitation, and exploring alternative resuscitation targets should be an essential research priority in sepsis.

Research objectives

To compare the 28-d mortality in two clinical patterns of septic shock: hyperlactatemic patients in the hypoperfusion context and hyperlactatemic patients in the non-hypoperfusion context.

Research methods

This prospective comparative observational study carried out on 135 adult patients with septic shock that met Sepsis-3 definitions compared patients of hyperlactatemia with hypoperfusion (Group 1, n = 95) and hyperlactatemia without hypoperfusion (Group 2, n = 40). The patients were observed for various macro and micro hemodynamic parameters at regular intervals of 0 h, 3 h, and 6 h. All-cause 28-d mortality and all other secondary objective parameters were observed at specified intervals.

Research results

The stratification of patients into hypoperfusion and non-hypoperfusion did not result in a significantly different 28-d mortality (24% vs 15%, respectively; P = 0.234). However, the patients within the hypoperfusion context with high P(cv-a)CO2 and CRT (P = 0.022) at baseline had significantly higher mortality than Group 2. Group 1 had a higher proportion of patients requiring vasopressin and the mean vasopressor-free days out of the total 28 d were lower in patients with hypoperfusion (18.88 ± 9.04 vs 21.08 ± 8.76; P = 0.011). The mean lactate levels and lactate clearance at 3 h and 6 h, CRT, and P(cv-a)CO2 at 0 h, 3 h, and 6 h were found to be associated with 28-d mortality in patients with septic shock, with lactate levels at 6 h having the best predictive value (area under the receiver operating characteristic: 0.845).

Research conclusions

Septic shock patients fulfilling the hypoperfusion and non-hypoperfusion context exhibit similar 28-d all-cause hospital mortality, although patients with hypoperfusion displayed a more severe circulatory dysfunction. Lactate levels at 6 h had a better predictive value in predicting 28-d mortality. Persistently high P(cv-a)CO2 (> 6 mmHg) or increased CRT (> 4 s) at 3 h and 6 h during the early resuscitation can be a valuable additional aid for prognostication of septic shock patients.

Research perspectives

Multicenter large scale trials should be conducted to further evaluate the role of CRT and PCO2 gap as markers for resuscitation in patients with septic shock.