Demystifying Lactate in the Emergency Department

Wardi, Gabriel; Brice, Jessica; Correia, Matthew S.; Liu, Dennis; Self, Michael; Tainter, Christopher

doi:10.1016/j.annemergmed.2019.06.027

Cited by 58 publications

(57 citation statements)

References 106 publications

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“…Additionally, elevated lactate can be attributed to varying different underlying pathological processes as a result of a combination of aerobic and anaerobic causes. 19,20 This adds complexity to early sepsis recognition by emergency staff and should to be assessed independently to discern the clinical relevance for each individual patient.…”

Section: Discussionmentioning

confidence: 99%

Examining the association between triage streamed treatment location and time to appropriate antibiotics in emergency department patients with septic shock

Ryan

Greenslade

Williams

2020

Emerg Medicine Australasia

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Objective: Early recognition and treatment for sepsis is critical in improving patient outcomes. The present study sought to examine whether triage location was associated with time to appropriate antibiotics in a cohort of ED patients with septic shock. Methods: Septic shock patients were identified from a database of ED patients admitted with infection. Demographic, clinical and outcome data were reported by triage location. Time to event analyses sought to identify the association between triage location and time to appropriate antibiotic. Secondary outcome variables included ED and hospital length of stay (LOS), 30-day mortality, and ICU admission. Results: Time to appropriate antibiotic administration was longer for those patients triaged to lower acuity (242 min) compared to higher acuity (98 min, P < 0.01) locations. After adjustment for severity of illness, hospital LOS, ED LOS and 30-day mortality were similar regardless of the triaged location. Admission to ICU was lower for patients triaged to lower (7.3%) compared to higher (47.3%) acuity treatment locations. Conclusions: We identified a subgroup of septic shock patients triaged to a lower acuity treatment location who received significant delays to antibiotics. This research area deserves closer examination to potentially recognise septic shock earlier in the continuum.

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Section: Discussionmentioning

confidence: 99%

Examining the association between triage streamed treatment location and time to appropriate antibiotics in emergency department patients with septic shock

Ryan

Greenslade

Williams

2020

Emerg Medicine Australasia

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“…The reason for this resides in the complexity of lactate metabolism and the heterogeneity of causes underlying its increased production and/or decreased removal [12,13].…”

Section: Discussionmentioning

confidence: 99%

“…Secondly, arterial lactate levels were measured using different laboratory methods and this may introduce a significant bias, which we attempted to mitigate using multilevel mixed-effects regression analysis. Thirdly, arterial lactate levels might have been affected by patients' conditions and treatment methods, such as renal replacement therapy, use of certain drugs, poor nutritional status, and therapies for acid-base abnormalities [12,13]. In such cases, the level of arterial lactate does not reflect the metabolic state of the patient at weaning from VA-ECMO.…”

Section: Limitationsmentioning

confidence: 99%

Prognostic Significance of Arterial Lactate Levels at Weaning from Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation

Biancari

Fiore

Jónsson

et al. 2019

JCM

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Background: The outcome after weaning from postcardiotomy venoarterial extracorporeal membrane oxygenation (VA-ECMO) is poor. In this study, we investigated the prognostic impact of arterial lactate levels at the time of weaning from postcardiotomy VA. Methods: This analysis included 338 patients from the multicenter PC-ECMO registry with available data on arterial lactate levels at weaning from VA-ECMO. Results: Arterial lactate levels at weaning from VA-ECMO (adjusted OR 1.426, 95%CI 1.157-1.758) was an independent predictor of hospital mortality, and its best cutoff values was 1.6 mmol/L (<1.6 mmol/L, 26.2% vs. ≥ 1.6 mmol/L, 45.0%; adjusted OR 2.489, 95%CI 1.374-4.505). When 261 patients with arterial lactate at VA-ECMO weaning ≤2.0 mmol/L were analyzed, a cutoff of arterial lactate of 1.4 mmol/L for prediction of hospital mortality was identified (<1.4 mmol/L, 24.2% vs. ≥1.4 mmol/L, 38.5%, p = 0.014). Among 87 propensity score-matched pairs, hospital mortality was significantly higher in patients with arterial lactate ≥1.4 mmol/L (39.1% vs. 23.0%, p = 0.029) compared to those with lower arterial lactate. Conclusions: Increased arterial lactate levels at the time of weaning from postcardiotomy VA-ECMO increases significantly the risk of hospital mortality. Arterial lactate may be useful in guiding optimal timing of VA-ECMO weaning.

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“…2 However, lactate may also be elevated due to varying conditions in the absence of tissue hypoxia through a variety of mechanisms. 3,4 Lactate levels can What was the major finding of the study? Increases in lactate or age, individually or in combination, were significantly associated with an increasing mortality risk.…”

Section: Introductionmentioning

confidence: 98%

Age-adjusted and Expanded Lactate Thresholds as Predictors of All-Cause Mortality in the Emergency Department

Cannon

Miller

Grow

et al. 2020

WestJEM

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Introduction: While numerous studies have found emergency department (ED) lactate levels to be associated with increased in-hospital mortality, little information is available on the role age plays in this association. This study investigates whether age is a necessary variable to consider when using lactate levels as a marker of prognosis and a guide for management decisions in the ED. Methods: This was a retrospective cohort study in an urban, tertiary-care teaching hospital. A total of 13,506 lactate levels were obtained over a 4.5-year period. All adult patients who had a lactate level obtained by the treating provider in the ED were screened for inclusion. The main outcome measure was in-hospital mortality using age-adjusted cohorts and expanded lactate thresholds with secondary outcomes comparing mortality based on the primary clinical impression. Results: Of the 8796 patients in this analysis, there were 474 (5.4%) deaths. Mortality rates increased with both increasing lactate levels and increasing age. For all ages, mortality rates increased from 2.8% in the less than 2.0 millimoles per liter (mmol/L) lactate level, to 5.6% in the 2.0-2.9 mmol/L lactate level, to 8.0% in the 3.0-3.9 mmol/L lactate level, to 13.9% in the 4.0-4.9 mmol/L lactate level, to 13.7% in the 5.0-5.9 mmol/L lactate level, and to 39.1% in the 6.0 mmol/L or greater lactate level (p <0.0001). Survivors, regardless of age, had a mean lactate level <2.0 whereas nonsurvivors had mean lactate levels of 6.5, 4.5, and 3.7 mmol/L for age cohorts 18-39, 40-64, and ≥ 65 years, respectively. Conclusion: Our findings suggest that although lactate levels can be used as a prognostic tool to risk stratify ED patients, the traditional lactate level thresholds may need to be adjusted to account for varying risk based on age and clinical impressions. [West J Emerg Med. 2020;21(5)1249-1257.] readily be obtained and used to identify patients at high risk of death, even prior to the development of hemodynamic instability. Poor organ perfusion, if not reversed, ultimately leads to organ dysfunction and failure, shock, and potentially death. The use of lactate levels has been shown to be a predictor of prognosis in diverse populations of critically ill patients ranging from trauma to septic shock. 5-10 In the last decade, there has been increased use and evaluation of lactate in the ED and these studies demonstrate that elevated lactate levels are

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Demystifying Lactate in the Emergency Department

Cited by 58 publications

References 106 publications

Examining the association between triage streamed treatment location and time to appropriate antibiotics in emergency department patients with septic shock

Examining the association between triage streamed treatment location and time to appropriate antibiotics in emergency department patients with septic shock

Prognostic Significance of Arterial Lactate Levels at Weaning from Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation

Age-adjusted and Expanded Lactate Thresholds as Predictors of All-Cause Mortality in the Emergency Department

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