I need to eat my words on this one, because now there’s data to show that there’s a benefit to rechecking lactate levels in septic patients, but not for the reasons why one would think.
During my rounds over the course of the weekend, I recall telling several nurses that there’s no data to suggest that trending lactates changes outcomes. This study, which came out last night, tells me I was wrong in saying that. A close examination of the data will show that it has nothing to do with the lactate itself. Rather the fact that the clinicians are prompted to “do something” in response to a number that makes us uncomfortable.
Plan of attack for the elevated lactate alarm
Okay, so the lactic acid is elevated. You’re going to do one or two or all three of the following:
a. start vasopressors
b. start antibiotics
c. give more fluids
That’s the kicker, we don’t know which of those interventions, or combination of which, are what decreased mortality. Maybe it just means that someone gave these patients more attention. It certainly just wasn’t the “checking the lactate” part. Lactate is just an alarm of sorts, we still need to be clinicians. I will suggest, though, that earlier initiation of antibiotics plays the most important role in decreasing mortality. There’s already data suggesting that earlier antibiotics leads to improved outcomes. I personally start vasopressors pretty early. I will share data in the upcoming weeks as to why I do that in my practice.
Why not just give more fluids?
Giving more fluids is only useful if the patients is fluid responsive. That means if you can prove that giving that fluid will increase the cardiac index/output or the stroke volume. Giving fluids just to make the blood pressure go up arbitrarily is just plain dumb. It’s 2019. We’re better than that.
Ultimately, early lactate measurement did not improve outcomes, nurses relaying the information to the doctors, ARNP’s, or PA’s did.
-EJ
If you are interested in going through my analysis on many questions lactate, lactic acid, and its metabolism, click here.
Citation:
Chen H, Zhao C, Wei Y, Jin J. Early lactate measurement is associated with better outcomes in septic patients with an elevated serum lactate level. Crit Care. 2019;23(1):351. Published 2019 Nov 11. doi:10.1186/s13054-019-2625-0
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