1. Prehospital lactate measurement as a tool
for initiating sepsis treatment – a review
Paul Davey
Auckland University of Technology, St John
Harry Misselbrook
St John, Auckland University of Technology

2. Session Overview
1. Sepsis overview
2. Lactate physiology review
3. Recognising severe sepsis
4. Lactate and sepsis
5. Literature review
6. Relevant research
7. Key messages

3. Sepsis Overview
• Severe sepsis and septic shock have
mortality rates of 30-50%
• Account for up to 45% of ICU admissions
• Higher mortality and incidence than
STEMI and stroke
• Complex pathophysiology which routinely
causes shock without significantly
abnormal vital signs

4. Lactate production
Glucose Glycolysis
O
OC
C
C
O
H3
O
OC
C O
H3C
H
H
Lactic acid
H
-
OC
H3C
HH OC
O -
+ H+
Lactate
Krebs
cycle and
ETC
Pyruvate
O2

5. Modified from: http://www.resusme.em.extrememember.com/wp-content/uploads/2010/02/lactates.jpg
Liver (& Lung) disease
Accelerated glycolysis
Congenital disorders
Thiamine deficiency
Anaerobic metabolism
Toxic and drug effects
Extracellular movement in alkalosis
Sepsis
Glucose
Pyruvate
Lactate
Acetyl
CoA

Adrenaline, salbutamol
Cori
cycle

6. Sepsis Recognition
• Paramedic recognition of sepsis poor
• Baez et al (2013) reported 9.8% of paramedics correctly
diagnosed sepsis in four case scenarios
• Robson screening tool = improved paramedic sepsis
diagnosis (75% v 12% no tool) Wallgren et al (2014)
• Recognisable signs of hypoperfusion not always present
• Cyptic or occult is organ hypoperfusion without
tachycardia or hypotension – up to 30% incidence
• In the absence of abnormal vital signs Lactate is the
definitive severe sepsis & septic shock assessment tool
Robson Screening Tool
Suspect sepsis if two or more of the
following are present
• Temp >38.3 or <36.0oC
• Heart rate > 90/min
• Respiratory rate >20/min
• Acutely altered mental status
• Serum glucose >6.6mmmol/L

7. Lactate Testing
Lactate > 4mmol/L is associated with much higher
mortality rates
Lactate has been proven to be a better indicator of
shock, risk, prognosis and mortality than any other
vital sign in sepsis
0
5
10
15
20
25
30
35
40
45
50
Non-sShock ShockLow Int High Low Int High
Non-shock Shock
28daymortality(%)
http://www.laktate.com/wp-content/uploads/2013/09/lactate-plus-meter1.png
p=0.001
p<0.001

8. Literature Review Summary
Objective
To review literature on the use of using portable lactate meters
in the prehospital environment to identify patients with severe
sepsis or septic shock and determine whether earlier treatment
based on lactate levels decreases sepsis mortality
Methods
Cochrane, Medline, CINAHL, Scopus, OVID and EBSCO using
terms lactate OR sepsis AND prehospital or emergency
medical services. Articles describing prehospital lactate
measurement were included for review

9. Literature Review Summary
Results
• Five studies were included for review
• All five reported lactate levels are correlated with increased mortality
and increased severity of multiple organ dysfunction
• Only one small trial was performed which found a 26.7% mortality
rate from all patients with severe sepsis versus 13.6% for those
patients who had lactate > 4mmol and received IV fluid therapy
Conclusion
• High lactate levels in sepsis are confidently linked to higher mortality
rates and level of organ dysfunction.
• Studies show lactate testing prehospitally could lead to more
patients being identified as having severe sepsis and thus treatment
initiated earlier, leading to decreased mortality rate.
• Large studies need to be conducted to confidently conclude that
prehospital lactate testing is beneficial

10. Prehospital Lactate Testing Trial
Guerra et al (2012) – Early detection and treatment of
patients with severe sepsis by prehospital personnel
• Paramedics identified severe sepsis patients by SBP <90mmHg,
MAP <65mmHG or venous lactate >4mmol
• Initiated standard shock treatment (20ml/kg IV fluid bolus and O2)
• Patients who self-presented to ED with severe sepsis had 26.7%
mortality versus 13.6% for those identified and treated enroute to ED
• 30% of patients had organ hypoperfusion with a normal blood
pressure but elevated lactate – without lactate testing they would not
have met criteria for O2 or IV fluid administration or early ED
notification

11. Key Messages
• Lactate levels are inextricably linked to sepsis mortality
rates
• Up to 30% of severe sepsis patients present with cryptic
shock – only identifiable by lactate measurement
• Prehospital trials have demonstrated lactate testing in
combination with a sepsis screening tool leads to earlier
recognition, treatment and significant decreased
mortality rates
• A larger RCT needs to be performed to confidently
determine the ability of lactate testing to reduce mortality
rates in the prehospital environment

12. References
Baez, A.A., Hanudel, P., Perez, M.T., Giraldez, E.M., and Wilcox, S.R. (2013). Prehospital Sepsis
Project (PSP): Knowledge and Attitudes of United States Advanced Out-Of-Hospital Care Providers.
Prehospital and Disaster Medicine, 28(2), 104-106. doi:10.1017/S1049023X12001744
Wallgren, U.M., Castren, M., Svensson, A.E., and Kurland, L. (2014). Identification of adult septic
patients in the prehospital setting: a comparison of two screening tools and clinical judgement.
European Journal of Emergency Medicine, 21(4), 260-265. doi:10.1097/MEJ.000000000000084
McClelland. G., Younger, P., and Byers, S. (2012). Lactate measurement in pre-hospital care: a
review of the literature. Journal of Paramedic Practice, 4(6), 329-334. Retrieved from
http://www.paramedicpractice.com/cgi-
bin/go.pl/library/article.cgi?uid=92111;article=pp_4_6_329_334;format=pdf
Guerra, W.F., Mayfield, T.R., Meyers, M.S., Clouatre, A.E., and Riccio, J.C. (2013). Early detection
and treatment of patients with severe sepsis by prehospital personnel. Journal of Emergency
Medicine, 11(3), 1-10. doi:10.1016/j.jemermed.2012.11.003