Lactate Monitoring

Reno1978, BSN, RN · Sep 28, 2010

I don't work ER, but we do ABGs at the bedside with an iStat and there are cartridges available that will run a lactate with the ABG. Typically, ER patients that end up tubed and heading my way in the ICU will have had an ABG with lactate completed prior to their arrival to the ICU. If it's not done in the ER, it's part of our standard orders for all ICU admissions. It's definitely helpful!

GreyGull · Sep 28, 2010

It's the same in most of the area hospitals I am familiar with and this is taken from the nationwide sepsis awareness along with post resuscitation monitoring.

If it is an emergent or critical patient we do the lactate with the ABG either with a point of care device or in the lab (Respiratory or Clinical Lab). In many places it is not a specific order but part of a set of protocols which are initiated for many different types of patients. Both RTs and RNs may have these protocols to get a lactate level initially and to run with whatever protocols/guidelines follow from those results.

MassED, BSN, RN · Sep 28, 2010

we draw lactate levels, it seems, on any patient who is ill. Definitely it's on a sepsis alert patients and any other critically ill patient. We draw it at the bedside and tube up to the lab on ice.

medic182 · Sep 28, 2010

Does a lactate level effect the way you treat a patient. I know it is a great indicator of cellular hypoxia and mortality, but is there a set protocol you follow. I.E. patient with stable vital signs but a lactate level of 5.0 would it change your treatment, or would you just treat more aggressively. Just thoughts I am putting out there.

Donnie, RN, CEN, EMT-P

GreyGull · Sep 28, 2010

There is a recommended national set of sepsis bundles which many hospitals have adopted and some have adapted them for specific goals with certain patients to form their own bundles which is why they are referred to as "guidelines".

Some things are fairly common:

serum lactate > 4mmol/L

obtain blood cultures before antibiotics

maintain mean arterial pressure (MAP) > 65 mm Hg

central venous pressure (CVP) of ≥ 8 mm Hg

central venous oxygen saturation (ScvO2) ≥ 70% or mixed venous oxygen saturation (SvO2) ≥ 65%

The above can be achieved with fluid and/or vasopressors.

If sepsis is suspected, we maintain high FiO2 therapy on the patient until lactate level is confirmed, ScvO2 monitoring is obtained and may continue for up to 24 hours unless lactate declines dramatically regardless of what ARDS protocol might also be in place.

MICPEricRN · Sep 28, 2010

In my ER, we draw a lactate level on any pt that comes in with any 2 of the SIRS criteria:

Body temperature 38 °C (100 °F).

Heart rate > 90.

Respiratory rate > 20 or a PaCO2

White blood cell count 12,000, or > 10% band forms.

We have a SIRS protocol, so if any two of the first three show up in the initial assessment, we can draw the lactate as part of the initial labs before the patient is seen by the doc. We enter the protocol order directly into the computer and tube the samples straight to the lab.

Editorial Team / Moderator · Sep 28, 2010

Yep, we have one of our physicians spearheading a sepsis/SIRS algorithm in which we order things upon triaging the patient based on vitals out of normal limits, including a chest x-ray, UA, CBC, CMP, lactate, and two sets of cultures. I can see some problems/waste in painting all patients with that broad brush (like anyone tachy with a fever ... oh, flu/strep season is going to be a lot of work!) but the doc made the point that early detection/intervention in cases of sepsis really decreases mortality. I've had a couple of patients who didn't look too bad, but their lactates were high and they really had some nastiness brewing.

We don't have the iStat capability in our ED, though. Wish we did!