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Relationship Between Peak Lactate and Patient Outcome Following High-Risk Gastrointestinal Surgery: Influence of the Nature of Their Surgery Elective Versus Emergency

Creagh-Brown, Ben C. BM, MRCP, PhD, DICM, FFICM; De Silva, A. Pubudu MBBS, MSc, MD; Ferrando-Vivas, Paloma BSc, PGCert; Harrison, David A. MA, PhD

doi: 10.1097/CCM.0000000000001567
Clinical Investigations

Objectives: The association between hyperlactatemia and adverse outcome in patients admitted to ICUs following gastrointestinal surgery has not been reported. To explore the hypothesis that in a large cohort of gastrointestinal surgical patients, the peak serum lactate (in the first 24 hr) observed in patients admitted to ICU following surgery is associated with unadjusted and severity-adjusted acute hospital mortality and that the strength of association is greater in patients admitted following “emergency” surgery than in patients admitted following “elective” surgery.

Design: A retrospective cohort study of all patients who had gastrointestinal surgery and were admitted directly to the ICU between 2008 and 2012.

Setting: Two hundred forty-nine hospitals in the United Kingdom.

Patients: One hundred twenty-one thousand nine hundred ninety patients.

Interventions: None.

Measurements and Main Results: Peak blood lactate in the first 24 hours of admission to critical care, acute hospital mortality, length of stay, and other variables routinely collected within the U.K. Intensive Care National Audit and Research Centre Case Mix Programme database. Elevated blood lactate was associated with increased risk of death and prolonged duration of stay, and the relationship was maintained once adjusted for confounding variables. The positive association between mortality and levels of blood lactate continued down into the “normal range,” without evidence of a plateau. There was no difference in the extent to which hyperlactatemia was related to mortality between patients admitted following elective and emergency surgery.

Conclusions: These findings have implications for our understanding of the role of lactate in critically ill patients.

Supplemental Digital Content is available in the text.

1Surrey Peri-operative Anaesthesia Critical care collaborative Research group (SPACeR), Faculty of Health and Medical Sciences, University of Surrey, Surrey, United Kingdom.

2Intensive Care Unit, Royal Surrey County Hospital, Guildford, United Kingdom.

3National Intensive Care Surveillance, Quality Secretariat Building, Castle Street Hospital for Women, Colombo, Sri Lanka.

4Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom.

Dr. Creagh-Brown contributed to the conception of the study. Drs. Creagh-Brown, Pubudu De Silva, Ferrando-Vivas, and Harrison contributed to the design, analysis, and interpretation of the study and drafting of the article for important intellectual content.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Dr. Creagh-Brown is employed by Royal Surrey County Hospital and lectured for Napp, BI, GSK, and Novartis (small honoraria for talks on inhaled therapies for asthma and chronic obstructive pulmonary disease). His institution received grant support from the Intensive Care Foundation (applied for a small grant for a research project unrelated to this). Dr. Pubudu De Silva is employed by Ministry of Health, Sri Lanka. The remaining authors have disclosed that they do not have any potential conflicts of interest.

This is the first description of an association between the measured peak lactate concentration and adverse outcome following gastrointestinal surgery. This is irrespective of whether elective or emergency surgery is performed and even when lactate levels are within the “normal” range the observation still holds. These data oppose a popular view that, to some extent, hyperlactatemia may be a benign adaptive response.

For information regarding this article, E-mail: ben@spacer.org.uk

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