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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com


EMCrit Podcast 208 – Felipe Teran on Why We are Doing CPR Wrong

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domingo, 6 de marzo de 2016

Lactate in Sepsis

emDocs - March 6, 2016 - Author: Hofmann E - Edited by: Koyfman A and Long B
"Clinical Bottom Line
It is hard to deny the overwhelming evidence demonstrating an association between lactate clearance and mortality. Despite the ongoing controversy regarding the optimal endpoints of early sepsis resuscitation and the source of hyperlactemia, lactate remains the best non-invasive marker of illness severity. Given the current data, a ≥ 10% lactate clearance at 6 hours is an appropriate marker to follow when resuscitating a septic patient. However, recent research by Puskarich et al. showed thatlactate normalization to < 2.0 mmol/L within the first 6 hours of resuscitation is superior to the rate of clearance.19 The best approach to current SSC guidelines when encountering a patient with systemic inflammatory response syndrome (SIRS) is to measure a lactate level and obtain blood cultures prior to giving antibiotics. If the MAP is ≥ 65 mmHG and initial lactate is < 2.0 mmol/L, all available data suggest that this patient has a low risk for MOSF and inpatient mortality and can go to the ward or an observation unit depending on other comorbidities. If the MAP is ≥ 65 mmHg and the initial lactate is 2.0 to 3.9 mmol/L, provide 2 L of crystalloid and start source specific antibiotics. Remeasure the lactate within 6 hours and if there is a ≥ 10% decrease in lactate clearance, admit to either the ward or the observation unit. If the lactate clearance is < 10% after 2L of crystalloid, provide an additional 1L of crystalloid, and admit to the ICU. If the MAP is ≥ 65 mmHg and initial lactate is ≥ 4.0mmol/L, provide either 3L or 4L of crystalloid within the first 6 hours depending on volume status and other comorbidities and admit to the ICU. If the patient presents with a MAP of < 65mmHg, begin fluid resuscitation, start source specific antibiotics, start norepinephrine targeted at a MAP ≥ 65 mmHg, and admit to the ICU."