Lactate: How Sick Is Your Patient
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Lactate: How Sick Is Your Patient

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Learn about lactate, lactate acidosis, sepsis, and how early goal directed therapy can save lives.

Learn about lactate, lactate acidosis, sepsis, and how early goal directed therapy can save lives.

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Lactate: How Sick Is Your Patient Lactate: How Sick Is Your Patient Presentation Transcript

  • Lactate: How Sick Is Your Patient? Littleton/Porter/Parker EMS Wayne Guerra, MD, MBA Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Objectives
    • What is lactate?
    • Pathophysiology
    • Why should I care?
    • Sepsis
    • Sepsis EMS Pilot Study
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Case
    • 73 yo female, family calls because of weakness.
    • She has no complaints except for nausea and vomiting x2
    • Meds: Remicaide, Lisinipril, Motirin, Vicodin
    • PMH: RA, Htn,
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Case contd.
    • 105/60, 95, 22, 100.6
    • Lungs: CTA
    • Ht: RRR
    • Abd: soft NT
    • Neuro: nonfocal
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Case contd./ED Course
    • WBC: 12 with 75 Neut, 5 Bands
    • 7: wnl
    • UA: 20-30 WBC, 1+ bact
    • CXR: wnl
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Case contd./ED Course
    • Treatment:
    • Tylenol
    • NS 250 cc/hr
    • Levoquin 500mg IV
    • Admit to Medicine
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Case contd./ED Course
    • Bed becomes available after 4 hours in ED
    • Vitals before going upstairs:
    • 82/40, 90, 20, 99.2
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Case contd./ED Hosp Course
    • Second IV placed
    • 1 liter NS bolus
    • SBP remains in 80s
    • Lactate: 5.5
    • Patient admitted to ICU
    • Dies after 4 days with ARDS and ARF
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • History
    • 1789: Carl Whilhelm Sheele identified lactic acid in sour milk
    • 1833: chemical structure identified
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • History
    • 1922: Otto Meyerhoff and Archibald V. Hill win Nobel prize for energy capabilities of carbohydrate metabolism
    • Accepted that lactate production caused acidosis
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • History
    • Late 1950s: Huckabee established:
    • Hypoperfusion -> Lactic Acidosis
    • 1976: Cohen and Woods:
    • ↓ Tissue Oxygenation -> Lactic acidosis
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Is Lactate Bad?
    • Correlation versus causation
    • Heart rate and septic shock
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Energy (ATP) Production
    • Aerobic
    • Anaerobic
    • Creatine Phosphate (CP-ATP)
    • CP + ADP -> C + ATP
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Aerobic ATP Production
    • Most complicated
    • Can utilize many types of fuel
    • Most efficient
    • Slowest process
    • Occurs within the mitochondria
      • Pyruvate + NAD -> CO2 + H2O + NADH
    • CoA acetyl-CoA
    • Krebs Cycle then produces ATP
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Anaerobic ATP Production
    • Very fast
    • Uses locally available glycogen (glucose)
    • Also called “Glycolysis”
    • Forced pathway with hpoperfusion
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Lactate Production: Glycolysis Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA 2 H+ Glycolysis 2 H+ Glycolysis
  • Lactate Production: Glycolysis
    • Body’s response is the Cori cycle
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Lactate Clearance: Cori Cycle Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA 2 H+ 2 H+ End Result: *Net loss 4 ATP *If unable to compensate ↑ lactate and acidosis (↑ H+)
  • Anaerobic Metabolism (Tissue Hypoxia)
    • Increased production of lactate and H+
    • Decreased utilization of lactate and H+
    • End Result
      • Increased Lactate
      • Acidosis
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Lactate Truths and Myths
    • Does not cause muscle burning or fatigue
    • Does not cause acidosis
    • Important source of fuel for glucose production in the liver
    • Good indirect measure of tissue hypoperfusion
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Definitions
    • Normal lactate:
      • Unstressed: 1-0.5 mmol/L
      • Stressed: < 2 mmol/L
    • Hyperlactatemia: 2-5 mmol/L
    • Lactic acidosis: usually > 5 mmol/L with associated metabolic acidosis
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Hyperlactatemia
    • Normal perfusion
    • Normal tissue oxygenation
    • Transient hypoperfusion
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Lactic Acidosis
    • Type A
      • Tissue hypoxia
        • Tissue hypoperfusion
        • Reduced arterial oxygen content
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Lactic Acidosis
    • Type B
      • Not due to tissue hypoxia
        • Type B1: (common disorders) hepatic failure, DM, cancer, renal failure
        • Type B2: (drugs and toxins) biguanides, alcohols, iron, isoniazid, salicylates
        • Type B3: is due to inborn errors of metabolism
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA http://emedicine.medscape.com/article/768159-overview
  • Most Common Diseases
    • Shock
      • Hemorrhagic
      • Septic
      • Cardiogenic
    • Respiratory failure
    • AKA
    • Anemia
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Most Common Diseases
    • Toxins
    • Glucose-6-Phospahte deficiency
    • Inborn errors of metabolism
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Treatment of Lactic Acidosis
    • Correct Tissue Hypoxia
      • Increase perfusion
      • Increase oxygenation
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Treatment of Lactic Acidosis
    • Increase Perfusion
      • Aggressive fluid replacement
      • Isotonic saline preferred
      • Avoid lactate containing solutions
      • Avoid vasoconstrictors
      • Treat underlying cause
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Treatment of Lactic Acidosis
    • Increase Oxygenation
      • High flow O2
      • CPAP
      • Intubation
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Treatment of Lactic Acidosis
    • NaHCO3
      • Can cause increase lactate and H+
      • Reserved for severe metabolic acidosis (<7.15)
    • NaHCo3 req =
    • (Bicarb desired – Bicarb observed) x .4 x BW(kg)
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Treatment of Lactic Acidosis
    • Experimental Therapies
      • Carbicarb
        • ½ NaHCO3 (sodium bicarbonate)
        • ½ Na2CO3 (sodium carbonate)
        • Animal studies only
        • Caused decreased lactate and improved pH
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Why
    • Pre-hospital vital signs ≠ hypoperfusion
    • Pain and Anxiety -> Epinephrine release
    • Occult hypoperfusion, compensated shock, cryptic sepsis
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Why
    • Identify occult hypoperfusion earlier
    • Initiate fluid resuscitation earlier
    • Increased urgency
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Golden Hour
    • Dr Adams Crowley
      • Maryland Shock Trauma
      • First statewide EMS
      • First civilian use of medical helicopters
    • Critics: Dr. Bryan Bledsoe
    • Trauma, Stroke, MI, Sepsis
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Why
    • Hypotension -> Increased M & M
    • Identify early
    • Initiate treatment and urgency
    • Prevent hypotension
    • The significance of non-sustained hypotension in emergency department patients with sepsis
    • http://icmjournal.esicm.org/journals/abstract.html?v=0&j=134&i=0&a=1448_10.1007_s00134-009-1448-x&doi=
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Can Lactate Level Measurement in the Pre-Hospital Setting Identify Occult Hypoperfusion? Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Pre-Hospital Lactate and Mortality Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Critical Care 2008, 12: R160
  • The prognostic value of blood lactate levels relative to that of vital signs in the pre-hospital setting: a pilot study Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Critical Care 2008, 12: R160: http://ccforum.com/content/12/6/R160
  • Netherlands Study Conclusions
    • Lactate level > 3.5 mmol/L identifies a high risk group with mortality of 41% (26% for <3.5)
    • Lactate level < 3.5 mmol/L had a NPV of 88% for mortality
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Netherlands Study Conclusions
    • Improvement in lactate levels in the EMS setting correlates with ↓ mortality
      • Hazard of death decreased 80% for every 63% decrease in lactate level in the pre-hospital setting
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Netherlands Study Conclusions
    • Lactate > 5 mmol/L & pH < 7.35
      • 75% Mortality
    • Lactic acidosis and shock
      • Median survival 28 hours
      • Only 17 % discharged from hospital
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Why
    • Vital signs cannot always predict hypoperfusion
      • In the hospital
      • In the EMS setting
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Future
    • Can the Netherlands results be duplicated?
      • Gunnerson, Richmond Virginia
    • What EMS Treatments -> ↓ Lactate
    • Sepsis EMS Pilot Study
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Sepsis Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Suit against Memorial Hermann claims negligence caused man's sepsis, death Mariana Bridi da Costa
  • Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Sepsis can strike, kill shockingly fast
  • Sepsis EMS Pilot Study
    • Sepsis
      • Estimated 215,000 deaths per year
      • Up to 40-50% mortality
      • 750,000 illnesses
    • AMI (2005 CDC Death Rates)
      • 151,004 deaths
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • What Can We Do?
    • Early assessment/recognition
    • Early Goal Directed Therapy
      • Reduces mortality up to 50%
    • Begins in the field with 911 response
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Pathophysiology
    • Bacterial Infection
    • Chemotaxis -
      • Secretes chemical signals – causes reactions
        • Capillary vasodilatation
        • Increased vascular permeability
        • Leukocytes (White Blood Cells) combat infection
    • Edema
      • Pain, redness and swelling
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Pathophysiology
    • Systemic infection
      • Can not maintain perfusion
    • Release of pro-inflammatory cytokines
      • Powerful vasodilators
    • Release of anti-inflammatory mediators
      • Inhibit production of inflammatory components.
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Pathophysiology
    • Respiratory System
    • Acute Respiratory Distress Syndrome (ARDS)
      • 40% Mortality Rate
    • Surfactant
      • Maintains alveolar tension
      • Decreases in sepsis
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • ARDS Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • SIRS
    • Systemic Inflammatory Response Syndrome
    • Causes:
      • Trauma
      • Severe Burns
      • Pancreatitis
      • Ischemia
      • Infection
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Infection MODS
  • SIRS – Signs and Symptoms
    • Two or More
    • Temperature:
      • >38 C (100.4 F) or <36 C (96.8 F)
    • Heart Rate:
      • >90 beats/min (Outside Factors?)
    • Respiratory Rate
      • >20 breaths/min (Mechanically Ventilated)
    • White Blood Cell (Leukocyte) Count
      • >12,000 or <4,000 or >10% immature
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Infection MODS
  • Sepsis
    • SIRS with documented or suspected infection.
      • Bacterial
      • Viral
      • Fungal
      • Protozoa
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Infection MODS
  • Sepsis – High Risk Factors
    • Higher Risk
    • Extremes of Age
    • Multiple co morbidities
    • Recent hospitalization
      • 2 million hospital acquired infections per year.
    • Cough Present
    • Indwelling Foley/IV
    • Wounds/Injuries
    • Para/Quadriplegic
    • Bedridden
    • Recent Antibiotic Use
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Infection MODS
  • Sepsis
    • Common Causes?
      • Pneumonia
      • Urinary Tract Infections
      • Abdominal Surgery
      • Cellulitis
      • IV Drug Users
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Infection MODS
  • Sepsis – High Risk Factors
    • Immune Compromised
      • Diabetic
      • Cancer - chemotherapy
      • HIV
      • Systemic steroids
      • Anti-rejection medications
        • Imuran, Cellcept, Neoral (cyclosporine), Myfortic
      • Powerful anti-inflammatory medications
        • Humira, Enbrel, Remicade
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Infection MODS
  • Septic Shock
    • Septic shock = sepsis + hypotension
    • Classic Distributive Shock Example
    • ALSO
    • Cardiac Function Compromised (Cardiogenic Shock)
    • Massive Fluid Shift (Hypovolemic Shock)
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA Infection MODS
  • MODS
    • Multiple Organ Dysfunction Syndrome
      • Damage or dysfunction to more than one organ
      • Mortality 20 to 100%
      • Most frequent target = lungs
        • Cell permeability
        • ARDS
      • Renal failure
      • Heart failure
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Sepsis Alert Pilot Study
    • Can septic patients be identified in the pre-hospital setting?
      • Does initiation of pre-hospital EGDT change morbidity and mortality?
      • Does Sepsis Alert change ED treatment?
      • Does Sepsis Alert change ED/Hospital morbidity and mortality?
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Sepsis Alert (SIRS Criteria)
    • > 18 years old
    • Not Pregnant
    • Two or More:
    • Temperature: >38 C(100.4 ° F) or <36 C (96.8 ° F)
    • Heart Rate: >90 beats/min
    • Respiratory Rate >20 breaths/min
    • And:
    • Documented/Known/Suspected Infection
    • And
    • Hypoperfusion
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Hypoperfusion
    • Three ways to determine:
        • Systolic BP less than 90
        • MAP < 65
        • Lactate > 4 mmol/L
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Mean Arterial Pressure (MAP)
    • Average pressure during cardiac cycle
    • MAP = (2*DBP) + SBP
            • 3
    • 60 is minimum for tissue perfusion
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • EMS Lactate Levels
    • Pre-hospital Lactate Meters
    • Developed for Endurance Athletes
    • Works like a glucometer
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Sepsis Alert Procedure
    • Assess Patient
      • Apply criteria to incident
      • If it fits:
        • Notify Hospital—no destination requirement
          • Not all hospitals participating
          • Presented at Metro physicians in 11-2008
        • Administer high flow O2
        • 2 large bore IVs
        • IV fluid boluses, according to protocol
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Pre-Hospital Treatment
    • All septic patients require:
      • Oxygen therapy
      • Fluids
        • Boluses – 500 cc initially
        • 20ml/kg titrated to increase in BP (5 mmHg indicates vascular response)
        • Carefully assess lung sounds
      • Dopamine
      • Check glucose, maintain above 80
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Sepsis Alert – ER Response Porter/Littleton/Parker
    • Goal is to provide EGDT if needed
    • Patient goes to large resuscitation room.
    • Hospital Staff
      • Nurse/ER Doc
        • Ultrasound
        • Central Line Kit
      • Lab for blood cultures
      • X-Ray for CXR
      • Respiratory Therapist for rapid lactate measurement
      • House Supervisor
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • EGDT
    • If treatment goals met within 6 hours:
      • Mortality decreased by 30-35%
      • Less overall IVFs administered
      • Less vasopressors administered
      • Decreased transfusions
      • Decreased hospital stay of 4 days
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • EGDT
    • Goal is < 6 hours for all treatments
    • Grade 1C Recommendations:
      • Central line placement
      • IV fluid boluses until CVP = 8-12
      • MAP between 65-90 mm Hg
      • Start vasopressors after CVP > 8
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • EGDT
    • Grade 2C Recommendation: ScvO2 ≥ 70%
      • Maximize oxygenation with intubation if necessary
      • CVP 8-12
      • MAP between 65 mm Hg and 90 mm Hg
      • Transfuse until hematocrit ≥ 30%
      • Use inotropic agents to improve cardiac output
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Sepsis Alert Criteria
    • 18 years and older
    • Not Pregnant
    • Two or more of the following:
        • Temperature (above 100.3 ° or below 96.8 °)
        • Pulse > 90
        • RR > 20
    • Suspected or documented infection
    • Hypoperfusion, as indicated by
        • BP < 90
        • MAP < 65 any one of these
        • Lactate > 4
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Case Revisited
    • 73 yo female, family calls because of weakness.
    • She has no complaints except for nausea and vomiting x2
    • Meds: Remicaide, Lisinipril, Motirin, Vicodin
    • PMH: RA, Htn,
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Case Revisited
    • 105/60, 95, 22, 100.6
    • Lungs: CTA
    • Ht: RRR
    • Abd: soft NT
    • Neuro: nonfocal
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Case Revisited
    • When asked directly patient admits to dysuria
    • SIRS Criteria Met
    • Infection Suspected
    • Lactate drawn by EMS: 4.4
    • Sepsis Alert Called
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Case Revisited
    • EGDT started immediately
    • First CVP: 4
    • Patient given 2 additional liters NS
    • Norepinephrine started
    • Admitted to ICU
    • Patient discharged home after 5 days
    Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA
  • Litteton/Porter/Parker EMS Wayne Guerra, MD, MBA