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In sepsis, lactate is bad and needs to be corrected immediately via aggressive fluid resuscitation, right?
Well, maybe. But it's complicated.
A brief thread on lactate in sepsis!
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Well, maybe. But it's complicated.
A brief thread on lactate in sepsis!
1/7
Elevated lactate is most commonly attributed to hypoperfusion 2/2 hypotension and we usually give fluid in response.
However, it can also be thought of as a reflection of endogenous epinephrine production, which stimulates aerobic glycolysis via beta-2 adrenergic receptors.
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However, it can also be thought of as a reflection of endogenous epinephrine production, which stimulates aerobic glycolysis via beta-2 adrenergic receptors.
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And lactate isn't all bad!
Lactate may serve as a protective metabolic fuel for the heart and brain during stress.
Still, lactate can help identify patients in shock who have a strong endogenous catecholamine response, indicating they need more intensive care.
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Lactate may serve as a protective metabolic fuel for the heart and brain during stress.
Still, lactate can help identify patients in shock who have a strong endogenous catecholamine response, indicating they need more intensive care.
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The role of trending lactate levels in sepsis resuscitation is unclear - MAP and UOP are likely better.
However, persistent elevation should draw extra attention to your management - notably your abx selection, if you have source control, and other possible etiologies.
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However, persistent elevation should draw extra attention to your management - notably your abx selection, if you have source control, and other possible etiologies.
4/7
DDx for lactatemia:
Type A (tissue hypoxia)
- hypovolemia
- shock
- local ischemia (mesenteric, limb)
- decreased oxygenation
- anemia
Type B
- increased adrenergic state (albuterol, cocaine, epinephrine)
- decreased krebs (thiamine deficiency, EtOH)
- liver dysfunction
5/7
Type A (tissue hypoxia)
- hypovolemia
- shock
- local ischemia (mesenteric, limb)
- decreased oxygenation
- anemia
Type B
- increased adrenergic state (albuterol, cocaine, epinephrine)
- decreased krebs (thiamine deficiency, EtOH)
- liver dysfunction
5/7
Note that sodium lactate administration, as in lactated ringers, is safe and potentially beneficial.
It's unlikely to lead to an elevated lactate level.
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It's unlikely to lead to an elevated lactate level.
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Moreover, epinephrine, previously avoided due to concerns about lactate generation, should be considered as a second-line vasopressor in septic shock.
At low doses, it acts as an inotrope, and at higher doses, it also acts as a vasoconstrictor.
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At low doses, it acts as an inotrope, and at higher doses, it also acts as a vasoconstrictor.
7/7
I hope you've found this helpful!
Follow me @ROKeefeMD for more clinical threads and pearls!
And check out @pointofcaremed for checklists, differentials, dotphrases, and pearls for this topic and many more!
Like/Repost the quote below if you can:
Follow me @ROKeefeMD for more clinical threads and pearls!
And check out @pointofcaremed for checklists, differentials, dotphrases, and pearls for this topic and many more!
Like/Repost the quote below if you can:
https://twitter.com/ROKeefeMD/status/1700094126568734800
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