Evangelos Ntrivalas, MD, PhD, HCLD/CC(ABB), D(ABMLI) Director of Medical & Scientific Affairs, North America
Nova Biomedical
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Evangelos Ntrivalas, MD, PhD, is a paid employee of Nova Biomedical, a designer and manufacturer of whole blood diagnostic technologies.
This prentation is intended to be educational and free from commercial content.
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I.Review the physiology of lactate production and clearance II.Describe the process of elevated blood lactate
III.Prent the pathophysiologic mechanisms of ptic shock IV.Review the diagnostic criteria of psis and ptic shock V.Prent clinical ca study – focus on lactate and psis VI.Review the clinical utility of lactate testing in the ICU VII.Discuss the conditions, other than psis, that can cau elevated lactate
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Historical facts
•Lactate (or lactic acid) was first isolated from sour milk in 1780 by the Swedish chemist Carl Wilhelm Scheele
•In 1808, Jöns Jacob Berzelius discovered that lactic acid is produced in skeletal muscles during exertion
•In 1856, Louis Pasteur discovered Lactobacillus and its role in lactic acid production
•Huckabee WE (1961)1and Cohen RD (1983)2described lactic acidosis
1.Huckabee WE. Abnormal resting blood lactate. I. The significance of
hyperlactatemia in hospitalized patients. Am J Med 1961;30:840-848
2.Cohen RD, Wood HF. Lactic acidosis revisited. Diabetes 1983;32(2):181-191
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• Conjugate ba of lactic acid • pKa for lactic acid to lactate is 3.9
• 2 optical isomers = L -Lactate and D -Lactate • Produced endogenously as a product of anaerobic metabolism
• Unstresd concentration of ~ 0.5-2.0 mmol/L
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~70%
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❝Unstresd = 0.5 – 2.0 mmol/L ❝
Strenuous exerci = 14 - 20 mmol/L
Production
Clearance
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Etiology = Overproduction of lactate and/or
decread ability to clear lactate
◦Hyperlactatemia (2.0-4.0 mmol/L) ◦Lactic acidosis (>4 mmol/L)
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❝
Type A – hypoxic (cardiovascular shock, psis, respiratory/cardiac failure, vere trauma, etc.)
❝Type B1 - miscellaneous dia (cirrhosis, fulminant liver failure, widespread malignant dia)
❝Type B2 - drugs and toxins (biguanides, methanol, ethanol, anti-retroviral Rx)
❝Type B3 – inborn errors of metabolism (G6P deficiency, PD/carboxyla deficiency)
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❝
Central laboratory ◦Enzymatic
❝Blood gas analyzer
◦Bionsor
❝Handheld devices
◦Enzymatic bionsors
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Proper specimen collection and processing techniques are
important for reliable lactate results
❝
U of tourniquet or clenching hands increas the lactate
vuvuzela>引道❝
Stability of lactate
glee◦Whole blood, room temperature: lactate increas by 30-50% (0.3 – 0.5 mmol/L) in 30 min
◦Sample on ice slows the increa
◦Glycolytic inhibitors (fluoride) slow the increa
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Best method for rapid lactate turnaround time?
Certain conditions require
rapid lactate results
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NACB – Evidence Bad Practice for Point of Care Testing
NACB 2007christ
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Surviving Sepsis Campaign
Turnaround Time
Lactate levels must be available in your institution with rapid turnaround time (within minutes ) to effectively treat verely ptic patients. An arterial blood gas analyzer located in the clinical laboratories usually satisfies this requirement. However, any means of rapid turnaround time is acceptable. In some cas, it will be esntial for hospitals to invest in adequate equipment in order to meet prent standards of care for ptic patients.
The technique of obtaining lactate by venipuncture typically carries a 24- to 48-hour turnaround time and will not be suitable to care for ptic patients. This technique also requires special collection conditions, such as without the u of tourniquet, which will likely hinder proper clinical care.
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❝Asssment of acid-ba disorders
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Monitoring the effectiveness of resuscitation ❝Pre-hospital triage biomarker ❝Fetal and Neonatal Monitoring
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Monitoring of lactic acidosis in anti-retroviral therapy
dasketball❝
Detection and management of psis and trauma patients
◦Monitoring and managing goal directed therapy and lactate clearance
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67-year-old male
Medical history : coronary artery dia, hypertension, and cirrhosis
亚洲瑜伽培训学院Signs and symptoms at ED • 5 days of cough •Fever •Anorexia •Malaimicromedia
•Tachycardia •Hypotension
•Severe respiratory distress •Oliguria
•Peripheral cyanosis
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