‘Cryptic shock’ important but not always very cryptic

October 22, 2011 by  
Filed under Acute Med, All Updates, ICU, Resus

Patients with severe sepsis and an elevated lactate who appear to be normotensive had a mortality similar to those presenting with hypotension. This is demonstrated in a new study on patients who were recruited to a study I have reported before.

The so-called ‘cryptic shock’ group was defined by a systolic BP of at least 90 mmHg, suggesting to me not so much that normotension and hypotension are prognostically equivalent, but that we should perhaps redefine hypotension in sepsis, as we should probably be doing in trauma. Alternatively (and preferably), the BP should be interpreted in the context of what is known to be or likely to be normal for that patient. For example, a systolic BP of 105 mmHg in a 75 year old male would be be ringing serious alarm bells for me in a febrile patient, and I would be working them up for severe sepsis from the start. Interestingly in this study, the cryptic shock group had a higher proportion of patients with diabetes and/or end stage renal disease – diagnoses one would expect to be associated with hypertension – and the median (and IQR) systolic BP in this group was 108 (92, 126). So, although this shock may have been ‘cryptic’ as opposed to ‘overt’ by the definition applied in the paper (a cut off of 90 mmHg), it is likely that some of the patients in the cryptic group were hypotensive compared with their usual blood pressure.

These observations do not detract from a key message the authors include in their discussion, with which I wholeheartedly agree:

“These data highlight the need to screen patients for signs of occult hypoperfusion, and given the high mortality rate associated with an elevated serum lactate, also suggest that patients with biochemical evidence of inadequate oxygen delivery despite normal blood pressure should be included in early sepsis resuscitation pathways.”

This paper makes an important contribution to the sepsis literature by warning against the dismissal of an elevated serum lactate in the setting of apparent haemodynamic stability as being a less acutely ill patient than one presenting with overt hypotension. It provides a reminder to check the lactate in patients with infection and signs of systemic inflammatory response, since this may provide the only early evidence of hypoperfusion.


Outcomes of patients undergoing early sepsis resuscitation for cryptic shock compared with overt shock

Resuscitation. 2011 Oct;82(10):1289-1293


Introduction We sought to compare the outcomes of patients with cryptic versus overt shock treated with an emergency department (ED) based early sepsis resuscitation protocol.

Methods Pre-planned secondary analysis of a large, multicenter ED-based randomized controlled trial of early sepsis resuscitation. All subjects were treated with a quantitative resuscitation protocol in the ED targeting 3 physiological variables: central venous pressure, mean arterial pressure and either central venous oxygen saturation or lactate clearance. The study protocol was continued until all endpoints were achieved or a maximum of 6 h. Outcomes data of patients who were enrolled with a lactate ≥4 mmol/L and normotension (cryptic shock) were compared to those enrolled with sustained hypotension after fluid challenge (overt shock). The primary outcome was in-hospital mortality.

Results A total of 300 subjects were enrolled, 53 in the cryptic shock group and 247 in the overt shock group. The demographics and baseline characteristics were similar between the groups. The primary endpoint of in-hospital mortality was observed in 11/53 (20%, 95% CI 11–34) in the cryptic shock group and 48/247 (19%, 95% CI 15–25) in the overt shock group, difference of 1% (95% CI −10 to 14; log rank test p = 0.81).

Conclusion Severe sepsis with cryptic shock carries a mortality rate not significantly different from that of overt septic shock. These data suggest the need for early aggressive screening for and treatment of patients with an elevated serum lactate in the absence of hypotension.

Comments

2 Responses to “‘Cryptic shock’ important but not always very cryptic”

  1. Andrew Walker on October 22nd, 2011 17:58

    Interesting results, but a screening test would ideally be sensitive, at the expense of specificity. While lactate appears relatively specific (liver disease, B-agonists notwithstanding), it’s not all that sensitive.

    Here’s some sobering stats from EMCrit:
    – in hypotensive sepsis, lactate was < 2 in ~10%, and < 4 in ~25%. These figures were remarkably consistent between two different papers quoted.

    You'd expect it perform even worse in normotensive sepsis, especially when "truly' normotensive.

  2. Matthew (ICN) on October 31st, 2011 15:36

    This paper, whatever its flaws may be, serves to remind us all of a core practice pricipal – whether it is a physiological value, a lab result or an image, interpret its meaning in conext. In other words, treat the patient, not just the number.