Diagnostic Performance of Certain POCUS Parameters to Predict Blood Lactate Levels in Non-Hypotensive Sepsis Patients
Article Sidebar
Main Article Content
Abstract
BACKGROUND: Blood lactate levels are crucial indicators for the detection of hypoperfusion in sepsis. However, the facilities for testing remain limited in many emergency departments (EDs). Point-of-care ultrasound (POCUS) is used to help assess the hemodynamic status of emergency patients, including those with sepsis and may have the potential to predict blood lactate levels.
OBJECTIVES: This study aims to demonstrate the diagnostic performance of certain POCUS parameters regarding the prediction of blood lactate levels in non-hypotensive sepsis patients.
METHODS: This cross-sectional diagnostic study focused on patients aged 18 and above without hypotension, but were suspected of sepsis with a National Early Warning Score (NEWS) of more than 4, who visited the ED of Maharaj Nakorn Chiang Mai Hospital between January and October 2023. Trained physicians performed relevant POCUS measurements on all participants, and the results were recorded. Positive POCUS parameters, including IVC-CI >50% collapsibility in spontaneous ventilation or >18% distensibility in mechanical positive pressure ventilation, LVOT VTI <18 cm, or LVEDD <25 mm or ‘LV kissing’, were blinded to assess the prediction of blood lactate levels ≥2 and ≥4 mmol/L. Diagnostic performance analysis was performed using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of POCUS parameters to predict blood lactate levels. The ROC curve was utilized to determine the area under the curve (AUC) to evaluate the accuracy of the predictions.
RESULTS: A total of 95 non-hypotensive sepsis patients were included. For identification of participants with blood lactate levels ≥4 mmol/L, any single positive POCUS parameter exhibited a sensitivity of 90.9% (70.8-98.9), specificity of 37.5% (26.4-49.7) (AuROC 0.64), and NPV of 93.1% (77.2-99.2). The POCUS parameter with the highest sensitivity was LVEDD <25 mm (72.7%), and with the highest specificity was LVOT VTI <18 cm (70.8%). The sensitivity of triple positive POCUS parameters was 18.2%, while specificity was 91.7%.
CONCLUSIONS: Sole utilization of ultrasound parameters may not be feasible for the prediction of lactate levels. However, in situations where the facility to measure blood lactate levels is not available, the absence of any positive findings in POCUS parameters such as IVC-CI, LVOT VTI, or LVEDD can be employed as an initial screening method for sepsis patients without hypotension in the emergency department, aiming to exclude lactate levels ≥4 mmol/L.
Thaiclinicaltrials.org number, TCTR20231011003
Article Details
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
References
Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med [Internet]. 2021 [cited 2023 June 25];49(11):e1063-e1143. Available from: https://journals.lww.com/ccmjournal/fulltext/2021/11000/surviving_sepsis_campaign__international.21.aspx
Pino RM, Singh J. Appropriate clinical use of lactate measurements. Anesthesiology 2021;134:637-44.
Jones AE. Lactate clearance for assessing response to resuscitation in severe sepsis. Acad Emerg Med 2013;20:844-7.
Contenti J, Corraze H, Lemoël F, Levraut J. Effectiveness of arterial, venous, and capillary blood lactate as a sepsis triage tool in ED patients. Am J Emerg Med 2015;33:167-72.
Levy B. Lactate and shock state: the metabolic view. Curr Opin Crit Care 2006;12:315-21.
ProCESS/ARISE/ProMISe Methodology Writing Committee; Huang DT, Angus DC, Barnato A, Gunn SR, Kellum JA, et al. Harmonizing international trials of early goal-directed resuscitation for severe sepsis and septic shock: methodology of ProCESS, ARISE, and ProMISe. Intensive Care Med 2013;39:1760-75.
Brown RM, Semler MW. Fluid Management in Sepsis. J Intensive Care Med 2019;34:364-73.
Casey JD, Brown RM, Semler MW. Resuscitation fluids. Curr Opin Crit Care 2018;24:512-8.
Shrestha GS, Srinivasan S. Role of point-of-care ultrasonography for the management of sepsis and septic shock. Rev Recent Clin Trials 2018;13:243-51.
Achar SK, Sagar MS, Shetty R, Kini G, Samanth J, Nayak C, et al. Respiratory variation in aortic flow peak velocity and inferior vena cava distensibility as indices of fluid responsiveness in anaesthetised and mechanically ventilated children. Indian J Anaesth 2016;60:121-6.
Thodphetch M, Chenthanakij B, Wittayachamnankul B, Sruamsiri K, Tangsuwanaruk T. A comparison of scoring systems for predicting mortality and sepsis in the emergency department patients with a suspected infection. Clin Exp Emerg Med 2021;8(4):289-95.
Sartelli M, Kluger Y, Ansaloni L, Hardcastle TC, Rello J, Watkins RR, et al. Raising concerns about the Sepsis-3 definitions. World J Emerg Surg [Internet]. 2018 [cited 2023 June 25];13:6. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5784683/pdf/13017_2018_Article_165.pdf
Nagi AI, Shafik AM, Fatah AMA, Selima WZ, Hefny AF. Inferior vena cava collapsibility index as apredictor of fluid responsiveness in sepsisrelated acute circulatory failure. Ain-Shams Journal of Anesthesiology [Internet]. 2021 [cited 2023 Sep 30];13:75. Available from: https://asja.journals.ekb.eg/article_329740_879d13351c71d0a0843eb0a9284b01b8.pdf
Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: rapid ultrasound in shock in the evaluation of the critically lll. Emerg Med Clin North Am 2010;28:29-56, vii.
Kaptein MJ, Kaptein EM. Inferior vena cava collapsibility index: clinical validation and application for assessment of relative intravascular volume. Adv Chronic Kidney Dis 2021;28:218-26.
Wang J, Zhou D, Gao Y, Wu Z, Wang X, Lv C. Effect of VTILVOT variation rate on the assessment of fluid responsiveness in septic shock patients. Medicine (Baltimore) [Internet]. 2020 [cited 2023 Sep 30];99(47):e22702. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7676570/pdf/medi-99-e22702.pdf
Feissel M, Michard F, Mangin I, Ruyer O, Faller JP, Teboul JL. Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness in ventilated patients with septic shock. Chest 2001;119:867-73.
Jung IH, Park JH, Lee JA, Kim GS, Lee HY, Byun YS, et al. Left ventricular global longitudinal strain as a predictor for left ventricular reverse remodeling in dilated cardiomyopathy. J Cardiovasc Imaging 2020;28:137-49.
Blanco P, Aguiar FM, Blaivas M. Rapid ultrasound in shock (RUSH) velocity-time integral: a proposal to expand the RUSH protocol. J Ultrasound Med 2015;34:1691-700.
Gohar E, Herling A, Mazuz M, Tsaban G, Gat T, Kobal S, et al. Artificial intelligence (AI) versus POCUS expert: a validation study of three automatic AI-based, real-time, hemodynamic echocardiographic assessment tools. J Clin Med [Internet]. 2023 [cited 2023 Mar 25];12(4):1352. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9959768/pdf/jcm-12-01352.pdf
Yildizdas D, Aslan N. Ultrasonographic inferior vena cava collapsibility and distensibility indices for detecting the volume status of critically ill pediatric patients. J Ultrason [Internet]. 2020 [cited 2023 Mar 25];20(82):e205-e209. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7705480/pdf/jou-20-82-e205.pdf
Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, et al. Recommendations for chamber quantification: a report from the American society of echocardiography's guidelines and standards committee and the chamber quantification writing group, developed in conjunction with the European association of echocardiography, a branch of the European society of cardiology. J Am Soc Echocardiogr 2005;18:1440-63.