Lactate?

[docB]

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The recent LLSA article on lactate level being indicative of increased M&M in the elderly, even the elderly without sepsis, was provocative. Is anyone ordering it routinely on all their elderly? If you have someone with an isolated bumped lactate but little else do you admit? Are the admitting doctor balking at this?

 

[BJJVP]

I always felt that lactate was not non-specific and not anymore sensitive than H&P and other labs. I did not order it routinely but started getting requests from the intensivists for lactate levels on borderline cases (ICU vs step-down). It never seemed to be helpful but I now routinely order it on potentially septic pts just to keep the ICU happy.

I am not an academic type guy and of course my experience is anecdotal, but I don't see it as being too helpful. I haven't read the article you mention but as far as I know, nobody in our group is routinely getting levels on all elderly pts unless they are considering sepsis or ischemic bowel.

 

[docB]

del Portal DA, Shofer F, Mikkelsen, ME, et al. Emergency department lactate is associated with mortality in older adults admitted with and without infections. Acad Emerg Med. 2010;17(3):260-268.

Here's the info on the LLSA article. I'm looking for a link to the abstract.

 

[Arcan57]

Lactate is definitely better than H&P at determining severity of sepsis, especially on your gorked out nursing home dwellers. I think it's a useful number to have on sick patients that don't have a disease process with other clear determinants of prognosis in order to determine IMU vs. ICU. I don't order it on old people just because, although our blood culture orders come bundled with a lactate so everyone who has an initial consideration of sepsis ends up with a lactate.

 

[dotcb]

I think its use is well established in sepsis, trauma, and shock in general. If you think your patient is ill and may have one of these problems, then it can be a reasonable screen for severity. It does not seem useful for MI, head injury, fractures, or respiratory problems (though it does come on ABG's or VBG's I order). I think it can be useful to triage sick patients who "look good" to a higher level of care (ICU) when they may be still compensating. At my shop we have a point of care VBG which includes K, hematocrit, and lactate. This test gets ordered a lot for trauma, sepsis, dialysis patients, GI bleeds, critical illness in general.

If the test gets ordered in error and is abnormal, I usually ignore it, try to explain it, or repeat it. We had some days where the test cartridges were defective (false elevations) and this was necessary.

 

[ORL10]

I think lactate, although a non-specific test, can help identify patients at risk of early decompensation. I think this is especially true in elderly who have nonspecific complaints (confusion, AMS, weakness the list goes on). In addition, although EGDT classifies patients with lactate >4 into one category, clearly there is a non-linear relationship in terms of outcomes. For example, a lactate of 4.5, is not the same as a lactate of 9, and as you start getting lactates that high it's usually do to a seizure, or severe ischemia somewhere.

I order lactate routinely on elderly patients who by history I am not sure what is going on, or if it is indicated by the history (abdominal pain concern for mesenteric ischemia, sepsis, etc... I also order it in patients with sepsis with a repeat in 2-3 hours to check how my resuscitation is going, i.e. clearing > 10% (I don't have the luxury of admitting to ICU within 2-3 hours, almost ever.)

In comparison to other tests like, BNP which has somehow crept into being ordered routinely in patients with shortness of breath, I think lactate gives me some prognostic value as well as helps tell me if I need to keep searching for another cause I haven't yet thought of, despite it being a non-specific test.

 

[WilcoWorld]

I check lactate in the following patients:

Those in whom I am considering sepsis.
Those in whom I am considering mesenteric ischemia.
Those who I want to get admitted, but can't find anything wrong with.

What I took from the LLSA article was that high lactates should be taken seriously in the elderly. I did not conclude that I should be getting lactates on all elderly patients.

As an aside - do NOT check lactates on your seizure patients (unless you think they're septic). It's always high, and it does nothing but complicate their course.

 

[docB]

I check lactate in the following patients:

Those in whom I am considering sepsis.
Those in whom I am considering mesenteric ischemia.
Those who I want to get admitted, but can't find anything wrong with.

What I took from the LLSA article was that high lactates should be taken seriously in the elderly. I did not conclude that I should be getting lactates on all elderly patients.

As an aside - do NOT check lactates on your seizure patients (unless you think they're septic). It's always high, and it does nothing but complicate their course.

Several people have mentioned that they use lactate. If you have a weak, old person with nothing specific and a reasonable work up but a lactate of say... 6 will your internists admit that or will they put up a fight?

 

[BJJVP]

Several people have mentioned that they use lactate. If you have a weak, old person with nothing specific and a reasonable work up but a lactate of say... 6 will your internists admit that or will they put up a fight?

Has this scenario happened to anyone? Has anyone seen a pt with just weakness and normal vitals, normal labs, but an elevated lactate? Someone above mentioned that lactate has been established in trauma and sepsis. But has anyone had a trauma pt with negative scans that looked good enough to be discharged end up with an elevated lactate and serious pathology? I am curious because I haven't been sold on the utility of the lactate level but I realize I am pretty much alone on this one.

 

[WilcoWorld]

Several people have mentioned that they use lactate. If you have a weak, old person with nothing specific and a reasonable work up but a lactate of say... 6 will your internists admit that or will they put up a fight?

The fight they put up is then asking for MICU to admit the patient.

 

[WilcoWorld]

Has this scenario happened to anyone? Has anyone seen a pt with just weakness and normal vitals, normal labs, but an elevated lactate?

Yes, but...

Someone above mentioned that lactate has been established in trauma and sepsis. But has anyone had a trauma pt with negative scans that looked good enough to be discharged end up with an elevated lactate and serious pathology? I am curious because I haven't been sold on the utility of the lactate level but I realize I am pretty much alone on this one.

They had nonspecific complaints, a normal WBC and maybe nothing abnormal on labs but some "mild" hyponatremia or a "little bump" in their creatinine or LFTs, but those patients didn't look good enough to be discharged.

I'm not supporting or doing "screening" lactates on well-appearing folks. I am using lactate to help me decide whether I need to keep looking for badness in people I'm concerned about.