Is it correct to include lactate in the new septic shock definition?

Uña Orejón, R.; Huercio Martínez, I.; Mateo Torres, E.; Jofré Escudero, C.; del Prado Ureta Tolsada, M.

doi:10.1016/j.redare.2017.09.013

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"apellidos" => "del Prado Ureta Tolsada" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Hospital Universitario La Paz, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Es correcta la inclusión del lactato en la nueva definición de sepsis?" ] ] "textoCompleto" => "The 3rd International Consensus Definition for Sepsis and Septic Shock recently confirmed the need to develop a new, easily understandable universal definition that would facilitate early and accurate detection. A group of experts defined sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection.<a class="elsevierStyleCrossRef" href="#bib0030">1</a>Septic shock is now defined as a clinical construct of sepsis that requires vasopressors to maintain a mean arterial pressure ≥ 65mm Hg with lactate > 2mmol/L. Therefore, hyperlactataemia is now an important bio-marker of cellular dysfunction that is likely related to tissue hypoxia secondary to hypoperfusion. Thus, lactate levels were established as a prognostic marker for patients with shock, and lactate clearance, more than serum lactate levels, has been established as a prognosis marker for septic shock.However, these statements are based on conventional concepts and are currently being questioned in the light of recent trials.Indeed, no correlation has been found between lactate levels and tissue oxygenation when muscular tissue pO2 is measured, even in late stages of septic shock.<a class="elsevierStyleCrossRef" href="#bib0035">2</a> Likewise, studies in experimental animals showed not correlation between hyperlactataemia and tissue hypoxia levels when septic shock was induced. Similar results were obtained when oxygen content was evaluated with hypoxia markers, regardless of whether it was studied in experimental animals or septic patients with increased lactate levels.New evidence suggests that sepsis-associated hyperlactataemia could be an adaptive response to stress, where adrenergic stimulation increases aerobic glycolysis. This adrenergic activation may improve energy demand through the aerobic pathway by a mitochondrial lactate oxidation complex that converts lactate back to pyruvate for entry into the Kreb's Cycle (36 ATP mol).Traditionally, lactate had been long considered a byproduct of anaerobic metabolism, producing only 2mol of ATP. By this logic, an increase in serum lactate would be an inherent consequence of anaerobic respiration in times of lack of oxygen. However, this approach is being overshadowed by a new hypothesis called “Lactate shuttle”, where a transporter facilitates lactate entry into the mitochondria in different tissues and can be used as an energy source under stress, thus reflecting an optimal energy recycle.<a class="elsevierStyleCrossRef" href="#bib0040">3</a> Furthermore, this same glycolytic product lactate may supply energy to highly threatened organs (brain, heart, kidney and liver), an effect known as a “Cell-cell lactate shuttle”.<a class="elsevierStyleCrossRef" href="#bib0045">4</a> Therefore, lactate may also reflect a defence mechanism against an insult. This was demonstrated by Wutrich,<a class="elsevierStyleCrossRef" href="#bib0050">5</a> who showed a positive correlation between serum lactate levels and better prognosis in patients with shock.In conclusion, hyperlactataemia can still be used as a marker of oxygen debt, but an increase in serum levels may not always respond to a negative situation, but rather to an adaptive survival process to stress. Early lactate clearance may provide a better prognosis than a simple static value, and given the lack of an alternative, it is still a good bio-marker for early detection of septic shock. However, serum lactate may needed to be reconsidered as the only reliable marker of tissue hypoxia. Instead, it may represent an essential energy source for survival in septic shock." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Uña Orejón R, Huercio Martínez I, Mateo Torres E, Jofré Escudero C, del Prado Ureta Tolsada M. ¿Es correcta la inclusión del lactato en la nueva definición de sepsis? Rev Esp Anestesiol Reanim. 2018;65:121." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Developing a new definition and assessing new clinical criteria for septic shock: for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Shankar-Hari" 1 => "G.S. Phillips" 2 => "M. Levy" 3 => "C.W. 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Brooks" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1113/jphysiol.2009.178350" "Revista" => array:6 [ "tituloSerie" => "J Physiol" "fecha" => "2009" "volumen" => "587" "paginaInicial" => "5591" "paginaFinal" => "5600" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19805739" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Early increase in arterial lactate concentration under epinephrine infusion is associated with a better prognosis during shock" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y. Wutrich" 1 => "D. Barraud" 2 => "M. Conrad" 3 => "A. Cravoisy-Popovic" 4 => "L. Nace" 5 => "P.E. Bollaert" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/SHK.0b013e3181e7e9ba" "Revista" => array:6 [ "tituloSerie" => "Shock" "fecha" => "2010" "volumen" => "34" "paginaInicial" => "4" "paginaFinal" => "9" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20523270" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006500000002/v1_201802090832/S2341192917302068/v1_201802090832/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006500000002/v1_201802090832/S2341192917302068/v1_201802090832/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192917302068?idApp=UINPBA00004N"]

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Revista Española de Anestesiología y Reanimación (REDAR) -the Spanish Journal of Anesthesiology and Resuscitation- is the scientific body of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy. This is a monthly journal (10 issues) that publishes scientific articles of all areas within its specialty: clinical anesthesia, resuscitation-intensive medicine and critical care, diagnosis and treatment of acute and chronic pain, urgent care and emergencies and studies on basic science and related fields. The journal accepts work in both Spanish and English.

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