Introduction with a case
Basic science: Understanding lactate in sepsis
(1) Elevated lactate in septic shock is not due to anaerobic metabolism
(2) Elevated lactate in septic shock is mostly due to stimulation of beta-2 adrenergic receptors
(3) Elevated lactate in shock might be a beneficial compensatory response
Clinical applications: Using lactate to our advantage
(1) Identification of occult shock: Lactate still works.
(2) Serial lactate levels to monitor a patient in septic shock? Unknown utility.
(3) Lactated Ringer's (LR): Still a physiologically sensible choice.
(4) Epinephrine in septic shock: Underutilized due to fear of lactate?
- Lactate production in septic shock is not due to anaerobic metabolism or low oxygen delivery. It is largely driven by endogenous epinephrine stimulating aerobic glycolysis via beta-2 adrenergic receptors.
- Lactate may have a protective effect, serving as a metabolic fuel for the heart and brain under conditions of stress.
- Elevated lactate is useful to identify occult shock (patients who are being maintained by a robust endogenous catecholamine release). These patients are at increased risk for deterioration and require more aggressive care.
- There is no clear evidence about what lactate adds to other resuscitation targets (e.g. blood pressure and urine output). If lactate is trended during sepsis resuscitation, it should be interpreted carefully in clinical context.
- Administration of sodium lactate is safe and potentially beneficial. This supports the use of lactated ringers as a resuscitative fluid.
- Epinephrine has often been avoided in the past due to concerns regarding lactate generation. Given that lactate is potentially beneficial, epinephrine should be re-considered as a second-line vasopressor. At low doses it works primarily as an inotrope, whereas at higher doses it also functions as a vasoconstrictor.
- Garcia-Alvarez M, Marik PE, Bellomo R. Sepsis-associated hyperlactatemia. Critical Care 2014; 18: 503.
- Marik PE and Bellomo R. Lactate clearance as a target of therapy in sepsis: a flawed paradigm. Open Access Critical Care 2013.
- [Lecture at SMACC Chicago – Will link to this when it becomes available]
- LR: LR vs. Plasmalyte/Normosol, LR is safe in hyperkalemia
- Vasopressin: Renal microvascular hemodynamics & vasopressin
- Norepinephrine: Early norepinephrine to stabilize the MAP in sepsis
- IBCC chapter:Guide to APRV for COVID-19 - April 8, 2020
- PulmCrit Theoretical Post – The COVID Severity Index (CSI 1.0) - April 2, 2020
- PulmCrit wee – Why the SCCM/AARC/ASA/APSF/AACN/CHEST joint statement on split ventilators is wrong. - March 29, 2020