Measuring Lactate in the Prehospital Setting - Patient Care - @ JEMS.com

[Ryan Mayfield]

I'm with chbare on this one. I'm not sold on the idea, yet. All we know from this study is that high levels of prehospital lactate are associated with a poorer outcome. We already know this from hospital based studies. Let's do some studies to see if we can change outcomes based on prehospital lactate testing. If it will change outcomes, great let's use it. I'm not fully convinced of the utility of lactate to begin with. Early goal directed therapy is great in theory but there are issues with it. The original Rivers study had a physician at the pts beside constantly monitoring the pt. In reality there is no way to do this. A modified form of EGDT is probably a good idea and could be more practical.

As an aside, this discussion demonstrates some of the problems with designing good EMS studies. Look at the differences in transport times we have. This just adds another confounding variable. Something that may be beneficial on a 3 hour transport may be useless on a 15 minutes transport.

We have been doing prehospital lactate as a part of identifying patients in septic shock since 2009. We have submitted our results and will hopefully be published soon. What we did find is that if EMS identifies the septic patient, even with a short transport, there is a decreased mortality, LOS, and intubation rates. It looks to have some of the biggest impact on cryptic sepsis were the patient is normotensive with an elevated lactate. I will be happy to share what we have learned with whoever wants to know.

This is not FDA approved but seems it will be in the distant future for Paramedics in the U.S. This will be great thing to have in PHC. Consider we in the Private Transports deal with "Septic" patients in the NH. God knows how long they've been hypo-perfusing...

http://www.jems.com/...ate-prehospital

There are meters out there that are FDA approved and CLIA waived that can be bought online.

[DartmouthDave]

Hello,

I agree and disagree with you RM.

Yes, identification and early goal direct therapy for sepsis improves outcomes. But, this could be achieved simply training Paramedic look for the SIRS/Sepsis criteria (low temp, high temp, high resp, high heart rate, low BP) as outlined in Surviving Sepsis.

In fact, the last ED I worked at triage looked for patients that meet the SIRS/Sepsis criteria and would call a 'Code Sepsis' to ensure a rapid and efficient treatment. It was very effective and did not require the use of expensive point of care testing for lactate.

Thank you,

[Ryan Mayfield]

Dave,

The paramedics are trained in the SIRS + Infection + Hypoperfusion (SBP or MAP or Lactate) model and call a sepsis alert if the patient meets these criteria. Lactate is just given as another form of hypoperfusion. Calling the alert allows the hospital to prepare for the arrival of the patient and the paramedics start fluid resucitation.

As to the need, let me ask you this. How many of your septic shock patients are cryptic? We found that in our patient population it is around 30%. Add to that the majority of septic shock patients are brought in by EMS (I can cite my source if needed, but its too early to find the paper) and we think it makes sense. Published mortality rates for EGDT patients are around 33%, last year our hospital system was in the single digits if EMS identified the septic shock patient and called an alert. The biggest difference in mortality is seen in the cryptic patient subset.

As for the price, its around $2-3 a test. Not free, but much less expensive than some.

Thoughts? We are always looking to improve our process.

Thanks,

Ryan