Pre-Hospital Lactate Pro

Point of Care Testing

Lactate Pro Meter

Lactate (Lactic acid)• Level – venous: 0.5 - 2.2 mmol/L

• An increased lactate level is an indirect measure of tissue hypoxia and a approximation of the magnitude, duration and potential severity of shock.

• Trending of lactate levels

– Can describe the natural history of sepsis

– Guide therapy

– Predict outcome

• Lactate Metabolism ->

• Removal

– 60% Liver

– 30% Kidneys

– 10% Heart/Muscle

Lactate Pro Meter

Lactate (Lactic acid)• Inadequate oxygen delivery

– Volume depletion or profound dehydration

– Significant blood loss

– Septic shock

– Profound anemia

• Disproportionate oxygen demands – Severe hypoxemia

– Prolonged carbon monoxide exposure

– Trauma

• Inadequate oxygen utilization – Hyperthermia

– Shivering

– Seizures

– Strenuous exercise

Lactate Pro Meter

Hypoperfusion/Hypovolemia

• Elevated blood lactate levels despite normal vital signs

(occult hypoperfusion) are good markers of mortality in

post-operative surgical patients.

• Occult Hypoperfusion can present with baseline vitals

signs and a marginally elevated lactate( ≥ 2.4mmol/L)

• Elevated lactate could be indicative of prolonged period

of end organ hypoxia.

– End organ anaerobic metabolism

Lactate Pro Meter

Cyanide & CO Poisoning• Cellular Hypoxia

• Cyanide changes the iron in hemoglobin from ferrous to

ferric oxide.

– Affecting oxygen binding properties

• CO has a 256x greater affinity for hemoglobin than does

Oxygen making it a competitive asphyxiate.

Lactate Pro Meter

Trauma• The data therefore indicates that not only the initial or the

highest lactate value but also the duration of hyperlactatemia can be correlated with the development of organ failure. These observations stress the importance of the initial resuscitation in the prevention of organ failure. Serial blood lactate measurements are reliable indicators of morbidity and mortality after trauma.

• Pre-hospital can be the initial value and initiate the resuscitation interventions.

• Electrocution

• Compartment Syndrome (not just acute trauma, prolonged elderly fall victim)

Lactate Pro Meter

TraumaITLS 7e pg 158

Lactate Pro Meter

Sepsis• Suspected or significant history of possible infection

• Serum level (≥ 4mmol/L)

• Trending these from patient contact through discharge is

valuable.

– Fluid therapy is established to help shed lactate due to a

direct correlation to high serum lactate to low pH’s.

Lactate Pro Meter

Organ Transplant• In patients whom are potential candidates need to meet

certain criteria.

• In terms of feasible lactate levels for organ donor

candidates depend on the program.

– The majority want levels to have remained below 16mmol/L

but some programs have raised their acceptable levels to

20mmol/L to increase candidate pools

• And most likely to mirror the trauma criteria

Lactate Pro Meter

Lactate Rises (other)• Liver Failure- Lactic acidosis unrelated to tissue hypoxia has

been described in patients with liver disease.

• Renal Failure

• ASA/Tylenol Overdose

• Prolonged muscular work seen in construction workers, etc.

• Stimulant use (Cocaine, PCP, and all the other synthetics

out today)

• Tazer Victims

• Runners, especially those long distance. The day after can

sometimes be the worst for those under-conditioned.

Lactate Pro Meter

Lactate Pro Meter

Adult&|&Shock&|Lactic&Acidosis&&

& &The$Prehospital$care$goal$is$to$identify$and$correct$compensated$/$uncompensated$shock$before$further$deterioration.$If$initially$confronted$with$decompensated$shock,$rapid$intervention$is$paramount.$An$increased$lactate$level$is$an$indirect$measure$of$tissue$hypoxia$and$an$approximation$of$the$magnitude$and$duration$of$the$severity$of$shock.$$$

Indications&for&Lactate&Determination&· Concern$for$Hypoperfusion$

· Documented$Hypoperfusion$

· SIRS$State$o Possible$Infection,$Burns,$Trauma,$Etc.$

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If lactate > 2 mmol:

-Infuse 30cc/kg 0.9% NaCl solution IV in all patient categories excluding trauma. Reassess patient and vital signs to necessitate further

fluid therapy.

-In trauma patients infuse 20cc/kg 0.9% NaCl solution IV in all patient categories excluding trauma. Reassess patient and vital signs to

necessitate further fluid therapy.

Repeat lactate determination after fluid infusion has completed and / or 20 minutes has elapsed after initiation of IV fluid therapy.

Refractory Hypotension: Consider Dopamine 10mcg/kg/min, with simultaneous 1000cc NaCl bolus.

Include lactate determination results when reporting to the receiving ED.

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