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Lactate in Sepsis

I receive the daily digest version of this list, so I apologize if someone preceded my reply with the same information.

We did an observational study in which we tested lactate levels in an undifferentiated SIRS population in the ED.  We selected higher acuity patients by only testing those in whom some form of phlebotomy was performed.  We found that lactate levels >= 4.0 were significantly associated with organ dysfunction, SBI, ICU admission and IV antibiotic/fluid bolus use in the ED (clinicians were blinded to lactate levels).  Positive likelihood ratio for organ dysfunction was moderate, at 5, but prevalence of elevated lactate in the general SIRS population was low, at 18/239 in our study.   http://www.ncbi.nlm.nih.gov/pubmed/23167859

I think more study is warranted, and hopefully additional multicenter data will be analyzed for this in the future.  For now, based on this data, I believe lactate to be an appropriate test in a population whose pre-test probability of sepsis with organ dysfunction is higher than the general SIRS population.  We've designed our sepsis protocols in Denver with a two-tiered approach (Yellow=high-risk patient with fever, Stat=critical illness) and both tiers are tested for lactate.  A lactate level >=4 mandates treatment according to our more intensive Stat protocol.  

Halden Scott
Children's Hospital Colorado
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