Our critical value triggering a phone call to the RN or MD is 4. This level was used as it drives a critical decision to initiate EGDT. As an emergency physician, this upper level is acceptable for me since the nature of my practice necessitates me to have reviewed all the labs in the few hours I provide care (I'll be aware of all lactate levels nearly real-time and can take appropriate action). For a patient on the inpatient floor, however, the attending physician may not know of results for 12-24 hours if not notified. Without knowledge of the result, the opportunity to re-evaluate the plan and potentially change the level of aggressiveness might be lost. If the physicians in your hospital generally agree a lactate level >2.2 would generally prompt a different approach at that point, then it seems prudent to set your critical value there. Maybe they will suggest 2.5 or 3. The goal around picking a critical value, therefore, are more about prompting an action - more aggressive fluid administration, potentially a transition to a level of care allowing closer monitoring, prompt to order a follow up lactate to follow its trend, etc. Here are two studies showing the how increasing lactate is independently associated with mortality - perhaps they will help provide some "scientific" support to your policy making.
Annals EM 2005; 46(3) Shapiro, Annals of EM 45 (5), 2005 Since the studies both show increased mortality even with lactates in the 2's, it seems reasonable to, at least, be considered "important" information; and sharing it with the physician will likely drive an action(s) to prevent worsening of condition - or getting to a lactate of 4!. Jeff Vespa, MD Medical Director, Quality and Patient Safety North Memorial HealthCare & Level I Trauma Center Robbinsdale, MN >>> "Coon, Joshua" 05/03/12 10:20 AM >>> Can anyone help me during my sepsis collaborative this year we are looking to implement Lactic acid as one of the values if critical it is reported. Has anyone established a critical result for lactic acid. We have in our policy that the values greater than 2.2 are high. No critical has been established. And does anyone have literature on this topic? Thanks . "Always the Best" Joshua Joshua Coon RN CEN Emergency Department Administrative Charge Nurse Florida Hospital Waterman (352) 253-3264
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