Having an elevated lactate in septic acid on admission is bad. Trending it, as studies that I have shown on this page does not change mortality. Seeing the numbers downtrend do give us that warm and fuzzy feeling inside, though. We give off a sigh of relief when that number becomes "euboxic". This article was published in April 2019 and authors explained the different mechanisms by which lactic acid is elevated in septic patients.
1. a deficit in oxygen delivery or extraction
2. shunting
3. stress
4. increased adrenergic stimulation
Notice that none of these mean that we have to drown the lactates with a bunch of fluids thereby diluting the value. We need to go after the etiology of it in a more specific manner. The authors of this study looked at the patients enrolled in the ALBIOS study (you know, the 2014 study where they sorted out that giving patients in septic shock albumin was good for depleting hospital resources but not a survival benefit? I guess I need to cover that trial on here) and used more than 1700 patients in whom lactate and central venous oxygen saturation were measured. They did a bunch of calculations and statistics that I am not going to cover here but you can click on the link for the article and go to town on it if you so wish.
Something really interesting was found in this study. The authors found that 1017 patients had a lactic acidosis but 57% of those patients had a normal serum pH. I would've thought that the number would have been lower. And it's not because these patients were on bicarbonate drip band-aids either.
The Early Goal Directed Therapy trial made us infatuated with checking central venous oxygen sats and our target was to get that to be over 70%. This study showed us that only 35% of that patients they looked at had a value less than 70%. 65% of patients with an elevated lactic acid had a normal or high ScVO2. Strange. We do know that the extremes of ScVO2 are bad and that ultimately ScVO2 has a number of limitations within itself. Anyway, I'm not going to dive too deep into all that, I'll leave it for the authors to explain.
All in all their main conclusion in this study, and the important takeaway is that lactate is not primarily created in sepsis by of the cells not receiving enough oxygen, but rather by impaired tissue oxygen utilization. This is a game changer. In my opinion, it doesn't mean that fluids are the answer, but rather, to find a way to help the tissues use said oxygen. Now let's all change our practice.
Don't take my word as gospel on all this, I could be wrong. Read the article for yourself. A hat tip to the authors.
-EJ
Link to Abstract
Gattinoni, L., Vasques, F., Camporota, L., Meessen, J., Romitti, F., Pasticci, I., … Marini, J. J. (2019). Understanding Lactatemia in Human Sepsis: Potential Impact for Early Management. American Journal of Respiratory and Critical Care Medicine.
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Link to Abstract
Gattinoni, L., Vasques, F., Camporota, L., Meessen, J., Romitti, F., Pasticci, I., … Marini, J. J. (2019). Understanding Lactatemia in Human Sepsis: Potential Impact for Early Management. American Journal of Respiratory and Critical Care Medicine.
Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.
The primary source of compensation I receive for this page and Instagram work is via Amazon Affiliates. All this free education you receive is much out of the kindness of my heart but I also like to receive a check every month from Affiliate Marketing. No one likes to work for free. The best part is that it's of no cost to you. Here's how it works.
You click on the link for Will Owens' awesome ventilator book here: https://amzn.to/2myFxYm and whether or not you purchase the book I receive a small commission for whatever you buy on Amazon for the next 24 hours at no cost to you. For every copy of the Ventilator book people have bought off of my affiliate links, for example, I have earned $0.85. I know it's not big money but it helps motivate me to keep on plugging along doing this heavy lifting in Critical Care. Thank you for supporting my work!
- My Amazon Store
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