For the past few months, I have been co-chairing a NYC-wide sepsis collaborative under the auspices of a hospital organization. 56 hospitals have joined the collaborative with the goal of breaking down the barriers to aggressive sepsis care in the ED.
The protocols and educational materials for the project will always be cross-posted here:
Many of the questions we have been getting relate to the use of lactate as a screen and an indicator of adequate treatment. Last week, I discussed these issues during a webinar. This podcast is the recording of that cast.
Here is the Lactate Reference Sheet
Other important info:
The emcrit webtext is now at crashingpatient.com and the blog has moved to http://emcrit.org
Scott Gallagher sent in the comment regarding commotio cordis as a cause of v-fib/v-tach in trauma patients. He is quite right to point out that ACLS works for these folks. Shock and use anti-dysrhythmics.
Here is a reference from the New England Journal:
NEJM 2010;362:917
Podcast: Play in new window | Download (26.6MB) | Embed
Hi, my name is Scott Weingart. 
A listener writes in:
Great post !!
While I listend to the podcast, I thought of Metformin as an often quoted cause for high lactate levels/acidosis. So I pulled up a Cochrane Review (Pubmed ID: 20393934). According to which:
“Average lactate levels measured during metformin treatment were no different than for placebo or for other medications used to treat diabetes. In summary, there is no evidence at present that metformin is associated with an increased risk for lactic acidosis when prescribed under the study conditions.”
So no baseline change in lactate in patients on M.
But what about patients on M who are septic, how much of an elevated lactate could be atributed to the Metformin, potentially misleading our clinical judgment? (i.e. making the patient look worse than he really is) Or should we leave it out of the equation even in a septic patient and just interpret the lactate level as it is?
I actually wanted to post this on your blog, but I wasnt sure if my e-mail would appear too, that’s why I write my comment per mail. If the e-mail of a blog response stays confidential, maybe a remark next to the box would be helpful!
Thanks and keep up the great work, very inspiring!
Luke
Luke,
Intriguing thought. I have never seen any lit showing metformin in normal doses should alter the accuracy of lactate for sepsis. Overdose is a different story.
Scott
Stupid question, I know, so I apologise in advance, but when you refer to the “show notes” on the podcast, is this just the entry here (on which I’m commenting), and which appears on my iPod? Or are there notes elsewhere?
Sorry to be so dim, buty I often hear you talking about references in the handout/shownotes etc., and am never quite sure where I should be looking.
Thanks
Alex
Alex,
It is a great question because I forgot to put the reference sheet up. It is here now. Show notes refer to the blog post that goes with each episode. So you went to the right place and the reason you could not find it is I had completely forgotten.
Much thanks–Scott
P.S
I was thinking in particular of the refs for venous vs arterial lactate, which I can’t seem to find. I’m not usre if this is me, the work computer and it’s odd access policies denying me a look at some pages, or something else.
Thanks for the help!
A
The lactate reference sheet was excellent!
Thanks,
Fred
glad you liked it, Fred
Harry Writes:
Hello Scott
Great podcast on lactate. However two lurking questions remain.
Firstly, what happened to the intro music?
Secondly, carrying the notion of the elderly not being able to generate super high lactates secondary to poor catchecolamine reserve, what about the patient that is on beta blockade.
Thanks
Harry
intro music will come back in 2011
your intuition regarding beta blockade is dead-on I think,
some data supports this, such as
http://www.ncbi.nlm.nih.gov/pubmed/10338406
however, I have no advice on how to lower the lactate cut-off in these pts to account for their beta-blockers
Hi,
The Lactate FAQ is great, but a nurse asked me if my Lactated Ringer’s (28mEq/L) can cause a false positive. Any knowledge on that?
Thanks
Eric
In pts with a normal liver, ~100 meq / hour is cleared, so in these patients no. In the cirrhotic, yes it may accumulate.
Lactate- is anion (base).. so, why does it cause acidosis?
Anions (neg charge) make you ACIDIC.
I know it’s a basic knowledge but it’s confusing.. do you mean that a base can be either negative or positive charged?
Hi Hassan,
Take a look at a tutorial on Peter Stewart’s Acid-Base which should make your understanding much more physiological (yes, like all of us, you have been taught many lies…)
http://www.anaesthetist.com/icu/elec/ionz/Findex.htm
enjoy!