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Lactate

Mel Herbert, MD MBBS FAAEM and Sara Crager, MD
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24:27
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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN
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03:47

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EM:RAP 2018 04 April Written Summary 535 KB - PDF

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Doug L. -

THANK YOU!!! This is perfect and sorely needed. The strength and conditioning community has been ahead of medicine for years in realizing lactate is just a response to stress and nothing more magical or ominous than that. Nobody is rushing to give an athlete liters of fluid IV after a workout when their lactate is over 4 (termed onset of blood lactate accumulation) so why are we blindly doing this to our patients? Thank you Sara and Mel for clearing this up! (lactate pun heavily intended).

David P. -

Sara Crager's segment on lactate was one of the best things I have heard on EMRap in a long while. The effect that the CMS sepsis guidelines has had on our utilization of serum lactate has totally skewed what we are doing, and the misperception of what an elevated lactate means has permeated all the way through our field from doctors to nurses to even techs and lab staff. Yes, it MIGHT be septic shock needing aggressive fluid resuscitation, but it might not be. The reminder to not narrow your differential too soon, and to treat the whole patient, not just a lab value, is invaluable. Not only is she clear in her thinking and her explanation of the subject, Dr Crager has a fantastically soothing radio voice. More rants from her anytime.

Edward C., M.D. -

Dr Crager,

We are developing a Practice Improvement project for our Surviving Sepsis Campaign that involves expediting transfers from the ED to the ICU. You mentioned that studies have shown patients who board in the ED have worse outcomes. Do you have those references so that I may share them with my ICU colleagues? Thanks!

Sara Crager -

Hi Edward, below are some references, hope this helps!

Chalfin DB, Trzeciak S, Likourezos A, et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med 2007; 35:1477-1483

Cline SD, Schertz RA, Feucht EC. Expedited admission of patients decreases duration of mechanical ventilation and shortens ICU stay. Am J Emerg Med 2009; 27:843-46.

Cardoso LT, Grion CM, Matsuo T, et al. Impact of delayed admission to intensive care units on mortality of critically ill patients: a cohort study. Crit Care 2011; 15:R28

Duke G, Green J, Briedis J. Survival of critically ill medical patients is time-critical. Crit Care Resusc. 2004; 6:261-67.

Young MP, Gooder VJ, McBride K, et al. Inpatient transfers to the intensive care unit: delays are associated with increased mortality and morbidity. J Gen Intern Med 2003; 18:77-83

J. B. L., M.D. -

Scott Weingart taught we should give fluid and lower the n umber- could we get his input?

Sara Crager -

Definitely would love to get further input from Weingart and others because this is definitely a complex and controversial topic. For me, I would absolutely give more fluid in the context of a high or persistently elevated lactate in any number of cases. In order to do so, however, I would need to believe that: 1) the lactate was elevated due to a shock state, and 2) the patient's shock state would be improved by the administration of fluids. So for example, I wouldn't give fluids to a patient who was well appearing, perfusing well clinically, with no other evidence of end organ dysfunction, and who I believed had an elevated lactate because they had just gotten a large amount of beta-agonists. In a patient who was clearly in shock, but I believed that the underlying case of shock was cardiogenic and the patient was volume overloaded, I would not give a fluids. If I have a patient in septic shock with an elevated lactate, I would give empiric initial fluid resuscitation, and then would give further fluids if they continued to appear fluid responsive (while keeping in mind that I should also continue to re-assess other causes of their persistently elevated lactate such as lack of source control, gut ischemia, etc). The question of relying more heavily on early fluids vs early pressors in septic shock is still very much open, and the latest PETAL Network trial (CLOVERS) is hopefully going to be getting us some evidence on this topic in the foreseeable future. Bottom line, if it is unclear IF or WHY the patient is in shock, it wouldn't be wrong to give initial fluids, but it should be done in tandem with trying to ascertain the answers to those two questions.

SHIH-CHIN C. -

"Janson et al study.
What can we conclude from this study? Septic patients do better if they get sophisticated reassessments every two hours. Not that patients do better with lactate trending."

One should consider the setting of an academic institution vs a community hospital.
I think forcing 2 lactates is beneficial at community hospitals, which is, most hospitals in the USA.

In an academic hospital, there are residents available day and night to check on the patient. Hence, frequent reassessments are performed, even without the 2nd lactate.

In a community hospital, the managing doctor is on the phone, on the computer logged in at the other end of the city. The doctor is not physically in the hospital. Thus, the doctor needs data points to be his/her eyes and ears.
Data points that can be pulled up on the computer, while you are logged in from the other end of the city.
Having the nurse record more vital signs, draw more blood, takes the place of resident reassessments.
In this way, forcing the nurse to come to the bedside, redraw blood, redocument vital signs, allows the tele-doctor to care for the patient better.
In the community, an ICU doctor covers 2, 3, or 4 hospitals. They are not able to be physically be in every building.
More lab tests do result in better decision making, in lieu of requiring the doctor physically being in this particular hospital 24 hours a day (which is physically impossible.)

In a community hospital, the consequence of not forcing 2 lactates is, no doctor, no nurse ever reenters the patient's room until the next day, as there are no assigned tasks.

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