Lactate use in Emergency Department

1. LACTATE USE IN DEM
PRANEEL KUMAR
BUNDABERG EMERGENCY DEPARTMENT

2. WHY USE LACTATE
• Relative lack of sensitivity of clinical signs to predict
the presence or absence of organ injury or tissue
hypo perfusion
• Lack of standardization in clinical examination
technique

3. SERUM LACTATE

5. DIAGNOSTIC BIOMKER

6. DIAGNOSTIC BIOMARKER
• Rivers E, Nguyen B, Havstad S, et al. Early goaldirected therapy in the treatment of severe sepsis
and septic shock. N Engl J Med 2001;345(19):1368–
77.
• Elevated lactate levels in severe sepsis or septic
shock before resuscitation coincided with low
central venous oxygen saturation (Scvo2)
• Reflective of tissue hypoxia

7. SCREENING

8. SCREENING
• Occult shock
- Identify patients with underlying tissue hypo
perfusion before the development of clinical
findings
- Depends on patient pretest probability and
likelihood ratio

9. PROGNOSTIC

10. PROGNOSTIC
• Shapiro NI,Howell MD, Talmor D, et al. Serum lactate
as a predictor of mortality in emergency department
patients with infection. Ann Emerg Med
2005;45(5):524–8;
•1278 adult patient

11. PROGNOSTIC

12. PROGNOSTIC
• Scott S, Antonaglia V, Guiotto G, et al. Two-hour
lactate clearance predicts negative outcome in
patients with cardiorespiratory insufficiency. Crit
Care Res Pract 2010;2010. Article ID 917053.

13. PROGNOSTIC
• Arterial lactate levels were measured on ED arrival
and at 1,2,6 and 25 hours later
• The predictive value of 2-hour lactate clearance
was evaluated for negative outcomes defined as
hospital mortality or need for endotracheal
intubation versus positive outcomes defined as
discharge or transfer to a general medical ward

14. PROGNOSTIC
• 2 hour lactate clearance of more than 15% was a
strong predictor of negative outcome
• P < 0.001
• Sensitivity of 86%,Specificity of 91%,PPV 80%
• 2 hour lactate clearance proved more accurate
than baseline lactate levels, the shock index,MAP
and the base excess
• 2hour lactate level were more reliable even the
baseine lactate level was only mildly elevated at
3mmol/l

15. TOOLS FOR MONITORING
INTERVENTION

16. TOOLS FOR MONITORING
INTERVENTION
• Jones AE, Shapiro NI, Trzeciak S, et al. Lactate
clearance vs central venous oxygen saturation as
goals of early sepsis therapy. JAMA 2010;303(8):

17. • 300 patients with severe sepsis were randomly
assigned to one of the 2 resuscitation protocols in
the first 6hours
• 1st – resuscitate to normalise CVP, MAP and SvCO2
of at least 70%( surviving sepsis campaign guideline)
• 2nd – CVP,MAP and lactate clearance of at least
10%
• Primary measure- in hospital mortality rate

18. • Outcome- patients with septic shock, who were
treated to normalize CVP and MAP, additional
management to normalize lactate clearance
compared with management to normalize ScvO2
did not result in significantly different in-hospital
mortality.