Lactate Kinetics as a Predictor of Survival in ACLF With Septic Shock: A Prospective Observational Study
试验速览
- 阶段
- 不适用
- 状态
- 尚未招募
- 入组人数
- 100
- 试验地点
- 1
- 主要终点
- Number of participants survived at day 7
研究概览
简要总结
Shock is a clinical state of tissue hypoxia. This hypoxia may be brought about by either decreased perfusion or the inability of the cell to extract oxygen in the presence of adequate perfusion. This causes cellular dysfunction. The most encountered form of shock seen in cirrhotics is septic shock. Septic shock has underlying cellular and metabolic abnormalities in addition to circulatory dysfunction. The circulatory dysfunction in sepsis is in the form of severe vasodilatation with high cardiac index. Cirrhosis is a state of hyperdynamic circulation. The mortality of septic shock in these group of patients is still higher. Sepsis-3 definition of septic shock describes it as a dysregulated immune response to an infection, leading to systemic inflammation, vasodilation, and organ impairment (3). Practically, to define septic shock it requires the lactate to be more than 2 mmol/L and there should be requirement of vasopressors after adequate fluid resuscitation.
Increased lactate levels can indicate tissue hypoxia, excessively rapid aerobic glycolysis, or reduced clearance. As lactate is a normal product of glucose and pyruvate metabolism, any increase in glucose metabolism and / or decrease in pyruvate metabolism will increase lactate generation. This was observed even in the presence of adequate tissue oxygenation. In sepsis, the inflammatory response appears to be associated with an increase in glycolysis and impaired pyruvate dehydrogenase activity. Thus, cytoplasmic pyruvate increases with greater lactate formation. The glycolytic enzyme complex lactate dehydrogenase (LDH) regenerates nicotinamide adenine dinucleotide (NAD) when pyruvate is reduced to lactate via a redox-coupled process in anaerobic glycolysis (Embden-Meyerhof pathway). Since lactate is overproduced and underutilised in tissue hypoxia due to poor mitochondrial oxidation, lactate has traditionally been used as a diagnostic marker for tissue hypoxia. However, up to 70% of the body's lactate elimination occurs in the liver
详细描述
• We hypothesise that delta lactate at 6 hours would be a better predictor of survival in patients of ACLF with septic shock when compared to admission lactate
Aim and Objective -
- Aim: To study the impact of measurement of dynamic change of lactate on outcomes in ACLF patients with septic shock
- Primary objective: Delta arterial lactate at 6 hours (delta lactate) as a predictor of survival at 7 days in patients of ACLF with septic shock
Secondary objectives:
- To study the lactate kinetics and lactate clearance at different time points (0, 6, 12,24,48 and 72 hours)
- Impact of delta arterial lactate and lactate clearance at 6h on the length of hospital stay, days of ventilation, time taken for reversal of shock and 28-day mortality
- Impact of oxygenation, respiratory acidosis, metabolic acidosis, anion gap
- Effect of etiology of ACLF on lactate kinetics
- Study the impact of type of infection (MDRO) on lactate kinetics
- Study the impact of therapeutic interventions ( CRRT - impact of CRRT in a subgroup / Fluids/ Vasopressors) on lactate kinetics in ACLF patients with septic shock at day 7
- To develop a dynamic predictive model incorporating lactate kinetics to improve risk stratification and prediction of 28-day mortality.
研究设计
- 研究类型
- Observational
- 观察模型
- Cohort
- 时间视角
- Prospective
入排标准
- 年龄范围
- 18 Years 至 70 Years（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Patients of Acute on chronic liver failure with septic shock (APASL, Sepsis -3 definitions)
- •Age 18-70yrs
- •Informed Consent
排除标准
- •Acute coronary syndrome, hemodynamically unstable arrhythmias
- •CKD stage 5
- •COPD with acute exacerbation
- •Acute CVA or Seizures
- •Extremely moribund patients
- •Hepato-cellular carcinoma (HCC), intrahepatic or extrahepatic malignancy
- •Diabetic ketoacidosis
结局指标
主要结局
Number of participants survived at day 7
时间窗: 7 days
次要结局
- Impact of delta arterial lactate at 6 hours on need of invasive ventillation (Yes/no)(7 days)
- Impact of lactate clearance at 6 hours on length of hospital stay (measured in days).(28 days)
- Need of ventilation(28 days)
- lactate clearance and delta lactate will be measured --> lactate clearance = (Initial lactate - current lactate) Initial lactate * 100, Delta lactate = Initial lactate - current lactate(72 hours)
- Length of hospital stay (measured in days).(28 days)
- The effect of need of renal replacement therapy (till day 7) on delta lactate at 6 hours(7 days)
- The amount of fluid resuscitated and its effect on delta lactate at 6 hours(7 days)
- Impact of delta arterial lactate at 6 hours on length of hospital stay (measured in days).(28 days)
- Impact of delta arterial lactate at 6 hours on number of days of invasive ventillation (Measured in days)(7 days)
- impact of lactate clearance at 6 hrs on number of days of invasive ventillation (Measured in days)(7 days)
- Number of patients with effect of ejection fraction / cardiac outout on delta arterial lactate at 6 hours(6 hours)
- Number of patients with number of patients with Noradrenaline requirement and effect on delta lactate at 6 hours(7 days)
- Coerrelation between presence or absence of respiratory acidosis on the delta lactate at 6 hours(6 hours)
- Days of ventilation(28 days)
- impact of oxygenation measured by PF ratio at 0H on delta lactate at 6 hours(6 hours)
- Number of patients with effect of anion gap at 0H if metabolic acidosis is present on the delta lactate at 6 hours(6 hours)
- To study the impact of presence or absence of multi drug resistant organism (in culture or PCR anallysis) on delta lactate at 6 hours(7 days)
- impact of lactate clearance at 6 hrs on need of invasive ventillation (Yes/no),(7 days)
- Correlation between presence or absence of metabolic acidosis with delta lactate at 6 hours(6 hours)
- The effect of number of days of continuous renal replacement therapy (till day7) on delta lactate at 6 hours(7 days)
- To study the effect of lactate kinetics on 28 day mortality and to study the other factors affecting 28 day mortality(28 days)