PRANEEL KUMARBUNDABERG EMERGENCY DEPARTMENT

LACTATE USE IN DEM

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

SERUM LACTATE

DIAGNOSTIC BIOMKER

DIAGNOSTIC BIOMARKER

• Rivers E, Nguyen B, Havstad S, et al. Early goal- directed 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

SCREENING

SCREENING

• Occult shock - Identify patients with underlying tissue hypo

perfusion before the development of clinical findings

- Depends on patient pretest probability and likelihood ratio

PROGNOSTIC

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

PROGNOSTIC

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.

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

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

TOOLS FOR MONITORING INTERVENTION

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):

• 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

• 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.