Don't take vitals, take lactate

Erasmus MC, Rotterdam, South Holland, Netherlands
Intensive Care Medicine (Impact Factor: 7.21). 12/2007; 33(11):1863-5. DOI: 10.1007/s00134-007-0679-y
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Available from: Xiaotong Han, Oct 01, 2015
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    • "The association between lactic acidosis and a poor prognosis has been known for decades. Bakker and Jansen even suggested that lactate was a better indicator of patient outcome than measuring observations and many intensivists use it as a guide to patient mortality [12]. Manini et al. demonstrated how serum lactate levels were a good prognostic marker when used to predict drug overdose mortality [13]. "
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    ABSTRACT: Metformin is a commonly used treatment modality in type 2 diabetes mellitus, with a well documented side effect of lactic acidosis. In the intensive care setting lactate and pH levels are regularly used as a useful predictor of poor prognosis. In this article we highlight how high lactate levels are not an accurate predictor of mortality in deliberate metformin overdose. We present the case of a 70-year-old Caucasian man who took a deliberate metformin overdose of unknown quantity. He had a profound lactic acidosis at presentation with a pH of 6.93 and a lactate level of more than 20mmol/L. These figures would normally correspond with a mortality of more than 80%; however, with appropriate management this patient's condition improved. We provide evidence that the decision to treat severe lactic acidosis in deliberate metformin overdose should not be based on arterial lactate and pH levels, as would be the case in other overdoses. We also demonstrate that appropriate treatment with hemodiafiltration and 8.4% sodium bicarbonate, even in patients with a very high lactate and low pH, can be successful.
    Journal of Medical Case Reports 08/2012; 6(1):230. DOI:10.1186/1752-1947-6-230
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    • "Hyperlactaemia arises from an imbalance between oxygen delivery (DO2) and tissue demand (type A hyperlacataemia). However, hyperlactaemia under conditions of adequate DO2 – as seen with impaired oxygen utilisation secondary to inflammatory responses and/or reduced clearance as in liver or renal failure – is also recognised, particularly among the critically ill (type B hyperlacataemia) (Cohen and Woods 1976; Luft et al. 1983; De Backer et al. 1995; Bakker and Jansen 2007). It is likely that some critically ill foals experience both type A and type B hyperlactaemia. "
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    ABSTRACT: Admission L-lactate concentration is a useful and commonly measured biomarker not previously prospectively evaluated in a large multicentre study of critically ill neonatal foals. To evaluate overall outcome and the association of survival and L-lactate concentration at admission ([LAC]ADMIT) by periparturient history, presenting complaint and clinicians' major diagnosis for ill neonatal foals. Thirteen university and private equine referral hospitals enrolled 643 foals over the 2008 foaling season. Case details, historical, clinical and clinicopathological data were entered into standardised spreadsheets then unified for analysis. Overall survival was 79% (505/643). Risk of nonsurvival increased with each 1 mmol/l increase in [LAC]ADMIT (odds ratio 1.14, P < 0.001). Mean arterial pressure had a small (r2 = 19.1) but significant (P < 0.001) association with [LAC]ADMIT. Foals experiencing known dystocia or premature placental separation had increased [LAC]ADMIT (P < 0.001). Single umbilical problems (excluding uroperitoneum), meconium impaction only and failure of passive transfer of immunity only had 100% survival. Six clinicians' major diagnoses had increased odds of nonsurvival for each 1 mmol/l increase in [LAC]ADMIT: 'sepsis'; 'unspecified enterocolitis'; 'unspecified colic'; 'unspecified trauma'; 'immune related (not failure of passive transfer of immunity)' and 'respiratory only'. CONCLUSIONS and potential relevance: Survival of critically ill foals is good but varies with peripartum history, presenting complaint and clinicians' major diagnosis. L-lactate concentration at admission proves its utility as a valuable prognostic biomarker in neonatal foals and its utility appears to vary with peripartum history and clinicians' major diagnosis.
    Equine Veterinary Journal 02/2012; 44 Suppl 41(s41):57-63. DOI:10.1111/j.2042-3306.2011.00509.x · 2.37 Impact Factor
    • "Therefore, we think that other columns with uniform structures and adsorbabilities similar to that of the PMMA column might be potentially useful. On the other hand, a recent paper has shown that the use of a single measurement of venous lactic acid, the results of which can be made available soon after admission to the emergency department, provides the clinician with a better risk assessment, possibly enabling a clearer direction to diagnosis and therapy, than a patient’s vital signs.[13] Another paper reported that in patients admitted with clinically suspected infection, the venous lactate level predicted 28-day in-hospital mortality independent of blood pressure and contributed significant prognostic information than that provided by other clinical predictors.[14] "
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    ABSTRACT: As an alternative method for acute blood purification therapy, continuous venovenous hemodiafiltration (CVVHDF) has been reported as an effective clinical treatment for critically ill patients, but the optimal column for performing CVVHDF remains controversial. We used direct hemoperfusion using a polymyxin B-immobilized fiber column (DHP-PMX) to treat 88 patients with septic shock. To determine the optimal acute blood purification therapy, we subsequently divided the patients into three groups: the first group underwent CVVHDF using a polymethylmethacrylate membrane hemofilter (PMMA) after undergoing DHP-PMX (28 cases), the second group underwent CVVHDF using a polyacrylonitrile membrane hemofilter (PAN) after undergoing DHP-PMX (26 cases), and the third group did not undergo CVVHDF after undergoing DHP-PMX (34 cases). The overall survival rate was 54.5%, and patient outcome was significantly related to the Acute Physiology and Chronic Health Evaluation (APACHE) II score, the sepsis-related organ failure assessment (SOFA) score, and the blood lactic acid value before treatment (all P<0.0001). Only the PMMA-CVVHDF group showed a better outcome (survival rate of 78.6%) compared with the other groups (P = 0.0190). In addition, only the PMMA-CVVHDF group showed a significant improvement in the blood lactic acid level on day 3 (P = 0.0011). Our study suggests that the PMX column might be effective during the early phase of septic shock, before a high level of lactic acid is present. Furthermore, a PMMA column might be the most useful column for performing CVVHDF after DHP-PMX treatment, as suggested by the blood lactic acid value.
    Indian Journal of Critical Care Medicine 10/2010; 14(4):175-9. DOI:10.4103/0972-5229.76080
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