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The Lactate “Debate” with Dr Seth Trueger

Gday,

I was lucky enough to record a new podcast with Dr Seth Trueger – inspired by the recent online discussions around lactate, or more specifically lactate-clearance as a marker, or a goal of therapy in the treatment of septic patients.

This is a topic my team will be covering at the ACEM Winter Symposium here in Broome this weekend.  It has been a weird preparation for our discussion in front of a whole bunch of ED Specialists – everytime I sit down to plan the talk I see another FOAMed resource or opinion which changes the landscape.

This podcast needs a bit of background in order for the whole conversation to make a bit of sense.

Lactate Clearance has been around for 10 years or so as a therapeutic goal – or at least of a marker of “winning” when we are resuscitating septic patients.

Nguyen, Rivers and co popularised lactate clearance as a marker of improvement in 2004 – a few years after the original EGDT trials by Rivers.

Then in 2009 Jones et al did a comparison between SvcO2 and lactate as markers to guide therapy in sepsis resuscitation – they showed they both worked equally as well.  Jones et al showed it was “non-inferior” to SvCO2 to guide resuscitation.

Then in March this year Prof. Paul Marik and Dr Renaldo Bellomo wrote a review article titled “Lactate clearance as a target of therapy in sepsis: a flawed paradigm.”  In this paper they utilise a lot of pathophysiology and common sense to show why the traditional concept of lactate as a marker of anaerobic metabolism was a flawed concept.

This provoked a short sharp retort from Dr Scott Weingart on his Emcrit podcast (much shorter than our longish dissection!)  Have a listen to his thoughts then carry on to our discussion.

I was supposed to be taking the position that lactate clearance is a flawed concept – and Seth was taking the pro stance.  But we pretty much ended up agreeing on everything!

OK.  Onto the podcast.  Love to hear you comments  Play below or DOWNLOAD Direct here

Casey

Comments

  1. nice discussion.

    My problem with “lactate clearance” is that people usually don’t define what they mean. I have variously heard people talk about relative clearance of lactate (eg 10% clearance; 50% clearance etc); normalisation of lactate (falling to below 2); absolute clearance of lactate or clearance rate (relative clearance per unit time eg a 10% fall over 6 hours)

    Wat do you use?

    • Good question Toby
      I think you are asking how long is a piece of string! 🙂
      10% clearance at 6 hours was my understanding of the Jones trial goals. But may need to be corrected

      As in our discussion – clearance is relative in clinical context
      Post ictal or arrest it would come down quickly
      In sepsis – maybe slower?
      I think it needs to be individualized to the patients’ context
      Sorry
      Wishy washy answer at best
      Casey

  2. Seth Trueger says:

    Many studies (incl the Jones trial) use clearance of 10% over 6 hours as their “definition” of lactate clearance. That never made much sense to me — that’s a tiny drop. If you go from a lactate of 9 to a lactate of 8.1 in 6 hours then you still have a patient with a lactate of 8.1 — and it’s 6 hours later!

    I don’t think there’s a clear definition of what “successful” clearance is. But it seems that more clearance is better, and even small elevations in lactate have been shown to be (in general) pretty bad.

    If you think of lactate as only 1 part of the overall clinical picture, then a hard & fast lactate clearance criterion doesn’t need to be precisely defined. I think the best answer is “enough.”

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