I agree, I have seen patients with adequate MAP and CVP but with continued rising lactate. Some turn out to have ischemic bowels which despite resuscitation and adequate antibiotics will need source control. This is the importance of not just relying on one parameter but to evaluate the whole patient.
Alexander Sy, MD, MBA, FCCP, FACP, FAASM Medical Director Community Critical Care Services Division of Pulmonary and Critical Care Duke Medicine Duke Raleigh Hospital 3400 Wake Forest Road Raleigh, NC 27609 Tel No. 919-862-5680 Fax No. 919-862-5636 [cid:[email protected]] From: Sepsisgroups [mailto:[email protected]] On Behalf Of Andy Bourgeois Sent: Friday, July 11, 2014 4:29 PM To: CARIANN M DAHLQUIST; [email protected] Subject: Re: [Sepsis Groups] lactic acid I'd argue that you need to trend lactate to check your work because a normal MAP, CVP and ScvO2 do not exclude worsening sepsis. Lactate gives an indirect measure of tissue oxygenation and improving lactate indicates improved perfusion. CVP is supposed to measure volume status (which I'd argue it does poorly), but adequate volume does not mean the tissues are receiving adequate oxygen. A low MAP should be corrected with fluids and/or pressors, but an adequate MAP also does not exclude tissue hypoxia. Patients with elevated lactate with otherwise normal hemodynamic parameters, so called "cryptic shock" are not that rare, and their mortality is high: 5.4% of patients in this study had a lactate > 4 with no hypotension - Levy MM, Dellinger RP, Townsend SR, et al; Surviving Sepsis Campaign: The Surviving Sepsis Campaign: Results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med2010; 38:367–374 The mortality of these patients with cryptic shock is the same as patients with overt shock. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3179778/ (Puskarich MA, et al. Outcomes of patients undergoing early sepsis resuscitation for cryptic shock compared with overt shock. Resuscitation. 2011 Oct;82(10):1289-93.) ScvO2 would be more reassuring if it were normal as it reflects the balance between oxygen delivery (DO2) and consumption (VO2). Too low (< 65%) means there is impaired tissue oxygenation, and too high (>80%) is sepsis means there is likely microvasculatory shunting. Both extremes have increased mortality. The number of patients with preexisting liver failure causing an elevated lactate is going to be a small minority in the general sepsis population. (How can you be assured that the liver failure is not from the sepsis itself? A good review in Critical Care in 2012: http://ccforum.com/content/pdf/cc11381.pdf) And in your example, even if lactate was 2.05 on initial draw, if it elevates to 6 after 3 hours, it is significant -- the patient has worsening shock regardless if there is underlying liver disease. Additionally, there was a study in Critical Care Medicine in 2001 that found "Splanchnic lactate release is uncommon in septic patients, even when hyperlactatemia is severe." (De Backer D1, Creteur J, Silva E, Vincent JL. The hepatosplanchnic area is not a common source of lactate in patients with severe sepsis.Crit Care Med. 2001 Feb;29(2):256-61.) All that to say, trending abnormal lactates (and even rechecking normal ones) is an important part of sepsis treatment. It is a grade 2C recommendation in the 2012 Surviving Sepsis Campaign guidelines. Hope that helps with your critical care people. -Andy Andy Bourgeois, MD, FAAEM Allied Emergency Physicians Simi Valley Hospital On Thu, Jul 10, 2014 at 1:55 PM, CARIANN M DAHLQUIST <[email protected]<mailto:[email protected]>> wrote: Hello, Inquiring how other facilities are doing with physicians obtaining the second lactic acid within 6 hours if initial was > 2mmol/L? I am having some push back from our Critical Care that feel as though this leads to additional labs being drawn that they do not feel are needed as they are treating the patient based on MAP, CVP, blood pressure, etc... They do have several good points such as a patient that has liver failure and has a baseline lactic of 2.05, why continue to drawn more labs? Any ideas or processes would be appreciated. Thanks. CariAnn CariAnn Dahlquist RN Quality Management Altru Health System | Grand Forks, ND 701.780.5339<tel:701.780.5339> phone | 701.780.1942<tel:701.780.1942> fax | [email protected]<mailto:[email protected]> ------------------------------------------------------------------------------------------------------------------- CONFIDENTIAL & PRIVILEGED COMMUNICATION This email and any files transmitted with it are confidential, may contain privileged or copyright information, and are intended solely for the use of the intended recipient. If you are not the intended recipient of this email, you are required to notify the sender immediately and delete this email from your system. 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