ISSN.
Bali Medical Journal (BMJ) 2012.
Volume 1.
Number 1:22-28 The Role of Blood Lactate Levels as Outcome Predictor of Isolated Traumatic Brain Injury Patients Laode RA.
Djoko W, 1Andi AI, 1Mansyur A, and 1Burhanuddin B Neurosurgery Division.
Department of Surgery.
Wahidin Sudirohusodo Hospital/ Faculty of Medicine Hasanuddin University.
Makasar-Indonesia Objectives: Traumatic brain injury (TBI) is accompanied by regional alterations of brain metabolism, reduction in metabolic rates and possible energy crisis.
This metabolic disturbance reflected by increase and accumulation of the brain lactate levels.
Objective of this study was to determine the correlation between abnormalities in lactate metabolism for predicting neurologic outcome after moderate or severe traumatic brain Methods: An observational prospective study in 60 patients with isolated TBI.
Blood sample taken from vein of the limbs after underwent initial resuscitation.
Serial assessment of the blood lactate level was measured in 1st, 2nd and 7th day with Lact2 Roche CobasA C-System.
Neurologic outcome assessed on 7th days using Modified GCS.
Results: On initial assessment, 38.
3% of patients with normal lactate (O 2 mMol/L), 61.
7% of patients was hyperlactatemia ( > 2 mMol/L).
In this study, it was obtained that the lower of GCS level, the higher of blood lactate level, and vice versa .
= 0.
In both treatment, there was a significant lactate clearance 24-hour as 96% A 32.
= 0.
49% A 40.
= 0.
, respectively.
No significant changes between blood lactate level on the 2nd and 7th day, both operative .
= 0.
p > 0.
neither conservative .
= 0.
p > 0.
While, there was no correlation between neurologic outcome with 24-hour lactate clearance .
= 0.
The higher of the initial blood lactate level, the patientAos outcome was worsen .
= 0.
Conclusion: There is a significant correlation between blood lactate level and severity TBI according to GCS The lower GCS level, the higher blood lactate level and vice versa.
This study also demonstrates that 24hour lactate clearance did not affect patientAos outcome, but more influence by initial blood lactate level.
Therefore, initial blood lactate level can used as an outcome predictor in TBI patients.
Keywords: traumatic, brain injury, lactate level, outcome INTRODUCTION TBI is a public health problem, that can lead to disability and death.
Even for the high incidence, there is mention as a silent global 1,2 In the United States reported about 1.
million people a year suffered of TBI, where about 270,000 people receiving treatment in hospital, with mortality rates reaching of 52,000 cases per 2 In Indonesia, there is no incidence national data reported.
However, brain injury cases reported from Dr.
Wahidin Sudirohusodo General Hospital Makassar was about 861 cases in the year The cases were increase in the year of 2006 become 817 cases and 1,078 cases in 2007.
About 24% are brain injuries and 17% are strong brain injuries.
Correspondence: Laode.
Address: Neurosurgery Division.
Department of Surgery.
Wahidin Sudirohusodo Hospital/ Faculty of Medicine.
Hasanuddin University.
Makasar-Indonesia Open access: w.
In a study reported that the mortality rate reached 9% in patients with diffuse injuries and 40.
in patients with focal injuries.
2 TBI most often occur due to traffic accidents, industrial/work accidents, falls, or violence, and generally in the form of "multiple system disorders", so the handling should be holistic.
Mortality and morbidity due to brain injury is certainly going to bring great impact on overall public health Understanding of the variability of outcomes of brain injury requires a careful and indepth study to reveal the relationship between initial injury severity and outcome, as well as the understanding of brain injury.
1,3 Some researchers proved that the primary brain damage due to trauma is considered irreversible and strongly influence patient outcomes.
However, the pathophysiolo gical changes that accompany such changes in the ultrastructure of the blood brain inflammation and others who may contribute to secondary brain injury that lasts over time.
It is ISSN.
Bali Medical Journal (BMJ) 2012.
Volume 1.
Number 1:22-28 still possible to be prevented and treated.
Therefore, although the severity of primary brain injury greatly affects patient outcomes, but these secondary factors involved responsible for the diverse outcome, still can be manipulated to protect and limit damage of brain tissue and functionally, so that patient outcomes could be better and cure rates of brain injury patients will increasingly tinggi.
1,2,4,5
Inflammation, for example, as well as other organs, is also an important part of the pathophysiology of TBI.
In an event of brain injury a proper balance between cytokines that cause inflammatory reactions .
ro-inflammator.
need to be concerned.
In order to limit and recover damages, as well as anti-inflammatory cytokine (IL-.
which restrict to limit the work of proinflammatory cytokines, that the event would likely cause adverse effects.
If the regulation is controlled by less excessive IL-10, producing TNF- leads to tissue damage, clearance tissue debris and imperfect journey toward chronic The study of Islam .
, found that although TNF in a high rate, when IL-10 levels still high, then the outcome will be better.
Meanwhile metabolic changes also occur in brain injury.
These metabolic changes thought to reflect changes in brain energy metabolism in response to trauma.
In addition, due to release of stress hormones such as catecholamines and adrenaline that will affect of increased 'metabolic The existence of these metabolic changes is a common condition found in any great trauma.
One effect is the occurrence of hyperglycemic and increased lactate production network that lasts a Hyperglycemia showed mobilization of glycogen reserves to meet energy needs, while the high lactate production reflects the depletion of energy supply and demand.
Based on the above facts, this study tries to reveal the relationship between changes in blood lactate levels in patients with closed brain injury and its role in influencing patient outcomes.
METHODS
This is an observational study with a prospective approach to evaluate the performance of patients at Sub-Section of Neurosurgery Department of Surgery Faculty of Medicine.
University Hasanuddin/Dr.
Wahidin Sudirohusodo Hospital Makassar.
The study took place between March and October 2010.
A number of 60 patients who met the criteria of the sample.
were recruited in this study.
Venous blood samples Open access: w.
were taken from the extremities of patients, then transmitted and checked on the Clinical Pathology Laboratory Section at Hasanuddin University School of Medicine.
Blood lactate levels were measured using the Roche Cobas A technology Lact2 C-System.
Statistical Analysis All data analyses were performed using the SPSS software V.
Values of p<0.
05 were considered to be indicative of statistically significant differences.
Pearson Correlation Coefficient was employed to determine the correlation and Paired-Samples T-Test for evaluating the different.
RESULTS
Characteristics of Samples During the study period from March to October 2010, a number of 60 patients were recruited and met the inclusion criteria (Table .
Table 1 Distribution of Study Sample (N = .
Parameter Sex Age .
GCS
GCS 6
GCS 7
GCS 8
GCS 9
GCS10
GCS11
GCS12
GCS13
Injury criteria storng capity trauma mild capity trauma Treatment Percent Blood Lactate Levels In this study, blood lactate levels for each patient was measured 3 times, i.
on the first day of admission .
eferred to lactate-.
, on the second ISSN.
Bali Medical Journal (BMJ) 2012.
Volume 1.
Number 1:22-28 day after the action .
perative/conservativ.
identified as lactate-2, and the seventh day after treatment refered as lactate-7, at the same time the patient outcome was assessed using Modified GOS Lactate-2 was identified as a 24-hour lactate On examination, it was found that 7% .
patients were hyperlactatemia with lactate-1 levels > 2mmol/L and 38.
3% .
patients were normolactatemia .
actate O 2 mmol/ L) as can be seen on Figure 1.
The average lactate1 levels was 2.
84 A 1.
44 mmol /L or in the range 9 Ae 7.
2 mmol/L.
Normolactatemia Hyperlactatemia Figure 1 Lactate-1 Levels Based on Hyperlactatemia Examination of lactate-2 levels indicates that the higerst value was 3.
6 mmol/L and the lowest 9 mmol/L on average of 1.
69 A 0.
mmol/L.
There were 14 patients with lactate > 2 mmol/L, in which 2 patients on examination lactate-1 were a normolactatemia and the rest 12 patients were hyperlactatemia.
For lactate-7, examination was carried out for 44 patients only, because 7 patients died before the day 7, and 9 patients went home before the For the 9 patients who went home were all in good condition (GCS.
with minimal complaint or without complaint, therefore, all of them were included on outcomes evaluation.
The average value of lactate-7 was 1.
69 A 0.
mmol/L, with the highest value of 3.
7 mmol/L and the lowest 0.
7 mmol/L.
In this examination, we observed that there were 10 patients with lactate > 2 mmol/L, 2 of them were normolactatemia since the examination of lactate-1, whereas 8 patients were those who from the beginning with Meanwhile, for 14 patients who were on lactate-2 examination found hyperlactatemia, 4 of them on lacatate-7 examination were found remained hyperlactatemia, 4 patients became normolactatemia, and 5 patients were not checked due to death .
and 3 patients went home before the examination.
Average Open access: w.
examination results for serial blood lactate levels are shown in Table 2.
Table 2 Average Examination of all Blood Lactate Parameter Lactate-1 Lactate-2 Lactate-7 Lactate Levels .
mol/L) Minimum Maximum Average 83A1.
69A0.
69A0.
Twentyfour Hours Lactate clearance Twentyfour hours lactate clearance is the decrease in percent of blood lactate levels from the initial lactate levels .
to the second value of blood lactate levels .
Patient Outcomes Patients outcome on this study was evaluated based on GOS Modified scale.
The results indicates that from 60 samples based on the seventh day examination, 65% .
were favorable, 23.
3% .
were unfavorable, and the rest 11.
7% .
were died as can be seen on Figure 2.
Favorable Unfavorable Death Figure 2 Distribution of Outcome Patients Association between Initial Blood Lactate levels and the Degree of Brain Injury To determine the relationship between initial blood lactate levels with the degree of brain injury (GCS) Pearson Correlation test was performed.
this study, it was obtained that there was a significant association between initial blood lactate levels with GCS with p = 0.
<0.
Twentyfour Hours Lactate Clearance Paired-Samples T-Test was applied to examine the association between the action with 24-hours lactate clearance.
Results of analysis indicates that there was a significant association ISSN.
Bali Medical Journal (BMJ) 2012.
Volume 1.
Number 1:22-28 between the action with 24 hour lactate clearance, as listed in Table 3 in both patients undergoing operative or conservative p = 0.
<0.
and p = 0.
<0.
, respectively.
Table 3 Association Between Action and 24-Hours Clearence Variable pair Mean lactate-1 and lactate-2 51A1.
65A1.
In this study we obtained that the only association observed was between lactate-1 and lactate-2.
the other hand, no association between lactate-2 and lactae-7 observed, indicates by p = 0.
> .
for operative and p = 0.
> 0.
for Correlation between 24-Hours Lactate Clearance and Patients Outcome Pearson Correlation was employed to test correlation between 24-hours lactate clearance and patients outcome, the analysis used the Coefficient test is considered significant if p <0.
Statistinya the test results are p = 0349 .
> 0.
, which means that there is no significant relationship between 24-hour lactate clearance with patient Correlation Between Daily blood lactate levels with Patients Outcome Pearson Correlation test was applied to determine correlation between daily lactate blood levels and patients outcome.
The results was presented on Figure 3.
Lactate-1 Lactate-2 Lactate-7 Figure 3 Correlation between Daily Blood Lactate Levels with Patients Outcome Open access: w.
DISCUSSION