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BACKGROUND Medicare requires that hospitals report on their adherence to the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). OBJECTIVE To evaluate the effect of SEP-1 on treatment patterns and patient outcomes. DESIGN Longitudinal study of hospitals using repeated cross-sectional cohorts of patients. SETTING 11 hospitals within an integrated health system. PATIENTS 54 225 encounters between January 2013 and December 2017 for adults with sepsis who were hospitalized through the emergency department. INTERVENTION Onset of the SEP-1 reporting requirement in October 2015. MEASUREMENTS Changes in SEP-1-targeted processes, including antibiotic administration, lactate measurement, and fluid administration at 3 hours from sepsis onset; repeated lactate and vasopressor administration for hypotension within 6 hours of sepsis onset; and sepsis outcomes, including risk-adjusted intensive care unit (ICU) admission, in-hospital mortality, and home discharge among survivors. RESULTS Two years after its implementation, SEP-1 was associated with variable changes in process measures, with the greatest effect being an increase in lactate measurement within 3 hours of sepsis onset (absolute increase, 23.7 percentage points [95% CI, 20.7 to 26.7 percentage points]; P < 0.001). There were small increases in antibiotic administration (absolute increase, 4.7 percentage points [CI, 1.9 to 7.6 percentage points]; P = 0.001) and fluid administration of 30 mL/kg of body weight within 3 hours of sepsis onset (absolute increase, 3.4 percentage points [CI, 1.5 to 5.2 percentage points]; P < 0.001). There was no change in vasopressor administration. There was a small increase in ICU admissions (absolute increase, 2.0 percentage points [CI, 0 to 4.0 percentage points]; P = 0.055) and no changes in mortality (absolute change, 0.1 percentage points [CI, -0.9 to 1.1 percentage points]; P = 0.87) or discharge to home. LIMITATION Data are from a single health system. CONCLUSION Implementation of the SEP-1 mandatory reporting program was associated with variable changes in process measures, without improvements in clinical outcomes. Revising the measure may optimize its future effect. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.

As a traditional Chinese sport, competitive martial arts routines have a long history. The competition rules are the unified norms and standards formulated for sports competitions. They are a yardstick for referees to judge the technical level and competitive ability of athletes and an essential basis for coaches during training. In particular, the new rules increase the difficulty of martial arts routines training and score, improve the balance movement of various groups, highlight the action specifications, increase the proportion of the score, and strengthen the scoring measures for the performance level. Subsequently, this puts higher requirements for the exceptional technical level of routine athletes. Therefore, it is vital to formulate scientific martial arts systematic training methods. This paper considers the above problem and current popular artificial intelligence technology and constructs a neural network algorithm to solve it. In addition, since lactic acid is a good monitoring indicator of the training load intensity and effect of martial arts routine exercises, this article also considers extensive lactate measurement data to construct martial arts systematic training methods. Through simulations, our experimental verification and the obtained results demonstrate the effectiveness of the proposed algorithm.

Background Sepsis is a leading cause of pediatric mortality worldwide. The implementation of sepsis bundles and clinical decision support (CDS) tools have been useful in improving sepsis recognition and treatment. Methods Interventions targeted the pediatric ICU (PICU) sepsis identification process and focused on implementation of multidisciplinary sepsis huddles prompted by an automated CDS tool. The primary outcome measure was days between delayed sepsis recognition, with secondary outcome measures of the percentages of patients receiving goal-directed evidence-based sepsis therapies, including antibiotics within 1 hour, rapid fluid bolus within 20 minutes, and lactate measurement within 1 hour. The researchers also tracked median time to antibiotics. Results Average days between delayed sepsis recognition improved from one episode every 9 days to one episode every 28 days. The percentage of patients who received antibiotics within 1 hour improved from 33.9% to 45.5%, received a fluid bolus within 20 minutes increased from 54.7% to 61.8%, and had a lactate measured within 1 hour increased from 59.4% to 71.1% post–CDS alert; none were statistically significant. Median time to antibiotics prior to CDS alert implementation was 1.53 hours, with improvement to 1.05 hours postimplementation (p = 0.03). Conclusion Implementation of multidisciplinary sepsis huddles and an automated CDS alert in the PICU led to an improvement in days between delayed sepsis recognition and a significant improvement in time to antibiotics.

Expecting ambulance clinicians to dependably differentiate the life-threatening organ dysfunction caused by sepsis from an inflammatory response to a non-infectious aetiology, relying upon vital signs and a physical examination of the patient alone, must be considered unrealistic. Although lactate measurement has been integrated into numerous prehospital sepsis screening tools, it is not yet measured routinely within UK ambulance services. Research has generally focused on whether handheld point-of-care lactate measurement devices are as accurate as laboratory analysis of venous or arterial samples. The weight of literature has concluded negatively in relation to this. However, there is potential for handheld devices to be used independently to monitor trends in lactate elimination or accumulation to inform decisions on the efficacy of prehospital interventions, or simply to report categorical data in terms of whether lactate levels are elevated or not. This offers UK paramedics the opportunity to improve sepsis care through the enhanced assessment of risk and acuity, the identification of patients with cryptic shock, more aggressive fluid resuscitation and advanced notification to receiving units.

Our aim was to determine the relationship between glucose and lactate amongst adult patients admitted to hospital via the emergency department. We performed a cross-sectional observational study of 2541 patients admitted via the emergency department who had an admission glucose and lactate measurement available. 23% of the whole cohort had a diagnosis of diabetes. Glucose and lactate were predictors of the primary outcome of critical illness defined as composite of intensive care unit (ICU) admission or in-hospital death. In the multivariable analysis, lactate but not glucose remained an independent predictor of ICU/in hospital death in the group without diabetes. In the diabetes group, both glucose and lactate remained independent predictors of ICU admission/ in-hospital death. Hyperglycaemia and hyperlactataemia are part of the metabolic response to critical illness. Lactate and a diagnosis of diabetes modify the relationship between glycaemia and critical illness.

In the commentary, the authors urge the Centers for Medicare & Medicaid Services to remove lactate measurement from the national Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) during the COVID-19 crisis.

Calismamiz, plevral efuzyonlu hastalarda transuda ve eksudayi ayirt etmenin guvenilirligini ve gecerliligini belirleyerek plevral laktat duzeylerini degerlendirmeyi amacladi.1 Temmuz 2017 ile 31 Ocak 2018 tarihleri arasinda bir universite hastanesine basvuran ve plevral efuzyon tanisi alan hastalar uzerinde yapilan prospektif, gozlemsel bir calismadir. Transuda ve eksuda plevral sivi siniflandirmasi Light kriterlerine gore yapilmistir. Calisma grubu pevral effuzyonlu toplam 169 hastadan olustu [99 (% 58.6) erkek ve 18-93 yas arasi (ortalama ± SS, 64.6 ± 16.1 yil)]. Hastalarin 44'u (% 26) eksuda ve 125'i transuda olarak degerlendirildi. Laktatin ortanca degeri eksuda hastalarda 3.20 mmol / L (min-maks: 0.90-14.3) ve transuda hastalarda 1.85 mmol / L (min-maks: 0.90-4.70) idi ve her ikisinin karsilastirilmasinda anlamli farklilik saptandi. (z: 5.894; p

Background Assessment of disease severity in patients with septic shock (SS) is crucial in determining optimal level of care. In both pre- and in-hospital settings, blood lactate measurement is broadly used in combination with the clinical evaluation of patients as the clinical picture alone is not sufficient for assessing disease severity and outcomes. Methods From 15th April 2017 to 15th April 2019, patients with SS requiring prehospital mobile Intensive Care Unit intervention (mICU) were prospectively included in this observational study. Prehospital blood lactate clearance was estimated by the difference between prehospital (time of first contact between the patients and the mICU prior to any treatment) and in-hospital (at hospital admission) blood lactate levels divided by prehospital blood lactate. Results Among the 185 patients included in this study, lactate measurement was missing for six (3%) in the prehospital setting and for four (2%) at hospital admission, thus 175 (95%) were analysed for prehospital blood lactate clearance (mean age 70 ± 14 years). Pulmonary, digestive and urinary infections were probably the cause of the SS in respectively 56%, 22% and 10% of the cases. The 30-day overall mortality was 32%. Mean prehospital blood lactate clearance was significantly different between patients who died and those who survived (respectively 0.41 ± 2.50 mmol.l−1 vs 1.65 ± 2.88 mmol.l−1, p = 0.007). Cox regression analysis showed that 30-day mortality was associated with prehospital blood lactate clearance > 10% (HRa [CI95] = 0.49 [0.26–0.92], p = 0.028) and prehospital blood lactate clearance Conclusion A prehospital blood lactate clearance

Background The measurement of lactate in emergency medical services has the potential for earlier detection of shock and can be performed with a point-of-care handheld device. Validation of a point-of-care handheld device is required for prehospital implementation. Aim The primary aim was to validate the accuracy of Lactate Pro 2 in healthy volunteers and in haemodynamically compromised intensive care patients. The secondary aim was to evaluate which sample site, fingertip or earlobe, is most accurate compared to arterial lactate. Methods Arterial, venous and capillary blood samples from fingertips and earlobes were collected from intensive care patients and healthy volunteers. Arterial and venous blood lactate samples were analysed on a stationary hospital blood gas analyser (ABL800 Flex) as the reference device and compared to the Lactate Pro 2. We used the Bland-Altman method to calculate the limits of agreement and used mixed effect models to compare instruments and sample sites. A total of 49 intensive care patients with elevated lactate and 11 healthy volunteers with elevated lactate were included. Results There was no significant difference in measured lactate between Lactate Pro 2 and the reference method using arterial blood in either the healthy volunteers or the intensive care patients. Capillary lactate measurement in the fingertip and earlobe of intensive care patients was 47% (95% CI (29 to 68%), p p p = 0.003) and no significant difference between capillary blood lactate in the earlobe and arterial blood lactate. Conclusion Our results showed that the handheld Lactate Pro 2 had good agreement with the reference method using arterial blood in both intensive care patients and healthy volunteers. However, we found that the agreement was poorer using venous blood in both groups. Furthermore, the earlobe may be a better sample site than the fingertip in intensive care patients.

Background: Evidence regarding the effect of time to lactate measurement on the relationship between the initial lactate level and mortality is limited. We aimed to investigate the relationships between time to lactate measurement, initial lactate level, and in-hospital mortality in critically ill patients with sepsis.Methods and Results: Of the 14339 eligible adult patients with recognized sepsis upon admission to the ICU based on the MIMIC-III database, the median value of initial lactate was 1.70 mmol/L (interquartile range [IQR] 1.20-2.80), and its detection time was 3.50 hours ([IQR] 1.31-10.24). The results of fully adjusted multivariate analyses demonstrated that lactate was positively associated with in-hospital mortality (odds ratio: 1.126, 95% confidence interval: 1.090 to 1.163, PDiscussion: The association of initial lactate with in-hospital mortality is likely to vary with delays in detection time (grouping based on the “1-hour bundle”) in critically ill patients with recognized sepsis upon admission to the ICU.

The aim of this article is to review the literature on lactate measurements in critical care and the current devices used to measure noninvasively and invasively. Lactate measurements are currently being used as a way to measure the severity of sepsis. Intravascular and subcutaneous devices are some of the ways that these measurements can be continuously gathered as well as point-of-care blood tests. New devices that are being currently used with athletes can measure lactate noninvasively. As the advance of technology continues to move at a fast speed, an evaluation of literature is needed to assess the continued support of lactate and the ability to move to noninvasive devices in critical care. A literature search was conducted in February 2020, using PubMed, CINAHL, MEDLINE, and Cochrane databases. There remains support for the use of lactate and continuous lactate monitoring; however, currently, noninvasive devices are not available for the critical care environment. There are invasive techniques that are being used to measure lactate continuously in critical care and are beneficial for the cardiac surgery population. The review of the literature on continuous lactate measurements produced evidence that supports prediction of morbidity and mortality. There are no current noninvasive lactate measurement devices that can be used in critical care, but they are being currently used in the athletic community. Invasive continuous lactate measurement devices are currently being used and beneficial.

Background To determine the value of ischemia-modified albumin (IMA) and IMA/albumin ratio (IMAR) in the diagnosis and staging of hemorrhagic shock (HS). Methods A pressure-targeted HS model was established in this study. The control and shock groups were monitored for 30 min and 60 min to simulate varying durations of exposure to HS. All subjects underwent invasive arterial monitoring during the experiment and were further divided into mild and severe shock groups based on decreases in mean arterial pressure (MAP). Biochemical and histologic comparisons were performed between the groups. Results Our results revealed higher IMA, IMAR, lactate, total oxidant status (TOS) and oxidative stress index (OSI) levels in both the 30- and 60-min shock groups compared to the control group. Concerning MAP-based shock staging, IMA, IMAR, lactate, TOS and OSI levels in the 30-min and 60-min mild and severe shock groups were higher than those of the controls. However, there was no significant difference between the mild and severe shock groups. A significant correlation was determined between all the biomarkers evaluated and HS-induced damage in various organs. This correlation was highest in lactate and IMAR levels. Conclusion IMA and IMAR levels may be used in the early diagnosis of HS and also have the potential for use in determining the severity of HS. IMA and IMAR measurement may also be considered as an alternative or in addition to lactate measurement in the diagnosis of HS.

Metabolic acidosis is prevalent among critically ill patients and the common cause of metabolic acidosis in ICU is lactic acidosis. However, not all ICUs can provide lactate measurement. The traditional method that uses Henderson-Hasselbach equation (completed with BE and AG) and alternative method consisting of Stewart and its modification (BDEgap and SIG), are acid-base balance parameters commonly used by clinicians to determine metabolic acidosis in critically ill patients. The objective of this study was to discover the association between acid-base parameters (BE, AGobserved, AGcalculated, SIG, BDEgap) with lactate level in critically ill patients with metabolic acidosis. This was an analytical study with a cross-sectional design. Eighty-four critically ill patients hospitalized in the ICU department Dr. M. Djamil Padang Hospital were recruited in this study from January to September 2016. Blood gas analysis and lactate measurement were performed by potentiometric and amperometric method while electrolytes and albumin measurement were done by ISE and colorimetric method (BCG). Linear regression analysis was used to evaluate the association between acid-base parameters with lactate level based on p-value less than 0.05. Fourty five (54%) were females and thirty-nine (46%) were males with participant's ages ranged from 18 to 81 years old. Postoperative was the most reason for ICU admission (88%). Linear regression analysis showed that p-value for BE, AGobserved, AGcalculated, SIG and BDEgap were 119; 0.967; 0.001; 0.001; 0.689, respectively. Acid-base balance parameters which were mostly associated with lactate level in critically ill patients with metabolic acidosis were AGcalculated and SIG.

We present the development of a droplet-based device for real-time continuous lactate measurement, highlighting how protocols from long-established homogeneous enzymatic assays require careful re-optimisation before their migration into miniaturised droplet-based microfluidics.

ObjectiveTo compare the accuracy of cord blood lactate measurement using gas analyzer and portable devices in order to assess possibility of implementation of these devices in clinical practice.MethodsWe performed a prospective observational study using 30 umbilical cord samples which were obtained immediately after birth. Portable electrochemical devices Lactate Scout (SensLab GmbH, Leipzig, Germany) and StatStrip Lactate (NOVA Biomedical, Waltham, MA, USA) were used to determine lactate level. A gas analyzer ABL800 FLEX (Radiometer Medical ApS, Brønshøj-Husum, Denmark) was used as a reference. Base excess (BE), pH, partial oxygen (pO2) and carbon dioxide (pCO2) pressure, hemoglobin (ctHb) and bilirubin (ctBl) levels were measured.ResultsThe mean umbilical cord blood lactate level determined by the gas analyzer was 5.85 ± 2.66 mmol/L (ranging from 1.4 mmol/L to 13.4 mmol/L). Lactate level estimated by Lactate Scout was 5.66 ± 2.65 mmol/L and did not significantly differ from the reference method level (P = 0.2547). The mean lactate level determined by StatStrip Lactate was significantly lower than by the gas analyzer – 4.81 ± 2.38 mmol/L (P 2and pCO2, ctHb and ctBl levels did not affect the accuracy of the lactate measurement in absolute units (mmol/L).ConclusionUmbilical cord blood lactate level measured by StatStrip Lactate was lower than estimated by the ABL800 FLEX gas analyzer. This shows the necessity to develop decision-making reference points separately for each device. Umbilical cord blood pH, BE, pO2and pCO2, ctHb and ctBl levels did not affect the accuracy of measurements by electrochemical portable devices.

Purpose This assesses the potential of measuring lactate in the human brain using three non-editing MRS methods at 7T and compares the accuracy and precision of the methods. Methods 1 H MRS data were measured in the right dorsolateral prefrontal cortex using a semi-adiabatic spin-echo full-intensity acquired localized sequence with three different protocols: (I) TE = 16 ms, (II) TE = 110 ms, and (III) TE = 16 ms, TI = 300 ms. T1 and T2 relaxation times of lactate were also measured. Simulated spectra were generated for three protocols with known concentrations, using a range of spectral linewidths and SNRs to assess the effect of data quality on the measurement precision and accuracy. Results Lactate was quantified in all three protocols with mean Cramer-Rao lower bound of 8% (I), 13% (II), and 7% (III). The T1 and T2 relaxation times of lactate were 1.9 ± 0.2 s and 94 ± 13 ms, respectively. Simulations predicted a spectral linewidth-associated underestimation of lactate measurement. Simulations, phantom and in vivo results showed that protocol II was most affected by this underestimation. In addition, the estimation error was insensitive to a broad range of spectral linewidth with protocol I. Within-session coefficient of variances of lactate were 6.1 ± 7.9% (I), 22.3 ± 12.3% (II), and 5.1 ± 5.4% (III), respectively. Conclusion We conclude that protocols I and III have the potential to measure lactate at 7T with good reproducibility, whereas the measurement accuracy and precision depend on spectral linewidth and SNR, respectively. Moreover, simulation is valuable for the optimization of measurement protocols in future study design and the correction for measurement bias.

Background and objectivesA clinical trial in 93 National Health Service hospitals evaluated a quality improvement programme for emergency abdominal surgery, designed to improve mortality by improving the patient care pathway. Large variation was observed in implementation approaches, and the main trial result showed no mortality reduction. Our objective therefore was to evaluate whether trial participation led to care pathway implementation and to study the relationship between care pathway implementation and use of six recommended implementation strategies.MethodsWe performed a hospital-level time-series analysis using data from the Enhanced Peri-Operative Care for High-risk patients trial. Care pathway implementation was defined as achievement of >80% median reliability in 10 measured care processes. Mean monthly process performance was plotted on run charts. Process improvement was defined as an observed run chart signal, using probability-based ‘shift’ and ‘runs’ rules. A new median performance level was calculated after an observed signal.ResultsOf 93 participating hospitals, 80 provided sufficient data for analysis, generating 800 process measure charts from 20 305 patient admissions over 27 months. No hospital reliably implemented all 10 processes. Overall, only 279 of the 800 processes were improved (3 (2–5) per hospital) and 14/80 hospitals improved more than six processes. Mortality risk documented (57/80 (71%)), lactate measurement (42/80 (53%)) and cardiac output guided fluid therapy (32/80 (40%)) were most frequently improved. Consultant-led decision making (14/80 (18%)), consultant review before surgery (17/80 (21%)) and time to surgery (14/80 (18%)) were least frequently improved. In hospitals using ≥5 implementation strategies, 9/30 (30%) hospitals improved ≥6 care processes compared with 0/11 hospitals using ≤2 implementation strategies.ConclusionOnly a small number of hospitals improved more than half of the measured care processes, more often when at least five of six implementation strategies were used. In a longer term project, this understanding may have allowed us to adapt the intervention to be effective in more hospitals.

Author(s): Boland, MPH, Lori L.; Hokanson, MD, Jonathan S.; Fernstrom, MPH, Karl M.; Kinzy, MS, Tyler G.; Lick, MD, Charles J.; Satterlee, MD, Paul A.; LaCroix, EMT-P, Brian K. | Abstract: Introduction: We aimed to pilot test the delivery of sepsis education to emergency medical services (EMS) providers and the feasibility of equipping them with temporal artery thermometers (TATs) and handheld lactate meters to aid in the prehospital recognition of sepsis. Methods: This study used a convenience sample of prehospital patients meeting established criteria for sepsis. Paramedics received education on systemic inflammatory response syndrome (SIRS) criteria, were trained in the use of TATs and hand-held lactate meters, and enrolled patients who had a recent history of infection, met ≥ 2 SIRS criteria, and were being transported to a participating hospital. Blood lactate was measured by paramedics in the prehospital setting and again in the emergency department (ED) via usual care. Paramedics entered data using an online database accessible at the point of care. Results: Prehospital lactate values obtained by paramedics ranged from 0.8 to 9.8 mmol/L, and an elevated lactate (i.e. ≥ 4.0) was documented in 13 of 112 enrolled patients (12%). The unadjusted correlation of prehospital and ED lactate values was 0.57 (pl 0.001). The median interval between paramedic assessment of blood lactate and the electronic posting of the ED-measured lactate value in the hospital record was 111 minutes. Overall, 91 patients (81%) were hospitalized after ED evaluation, 27 (24%) were ultimately diagnosed with sepsis, and 3 (3%) died during hospitalization. Subjects with elevated prehospital lactate were somewhat more likely to have been admitted to the intensive care unit (23% vs 15%) and to have been diagnosed with sepsis (38% vs 22%) than those with normal lactate levels, but these differences were not statistically significant. Conclusion: In this pilot, EMS use of a combination of objective SIRS criteria, subjective assessment of infection, and blood lactate measurements did not achieve a level of diagnostic accuracy for sepsis that would warrant hospital prenotification and committed resources at a receiving hospital based on EMS assessment alone. Nevertheless, this work provides an early model for increasing EMS awareness and the implementation of novel devices that may enhance the prehospital assessment for sepsis. Additional translational research studies with larger numbers of patients and more robust methods are needed. [West J Emerg Med. 2016;17(5)648-655.]

1H MRS measurements of lactate are often confounded by overlapping lipid signals. Double-quantum (DQ) filtering eliminates lipid signals and permits single-shot measurements, which avoid subtraction artefacts in moving tissues. This study evaluated a single-voxel-localized DQ filtering method qualitatively and quantitatively for measuring lactate concentrations in the presence of lipid, using high-grade brain tumours in which the results could be compared with standard acquisition as a reference. Paired standard acquisition and DQ-filtered 1H MR spectra were acquired at 3T from patients receiving treatment for glioblastoma, using fLASER (localization by adiabatic selective refocusing using frequency offset corrected inversion pulses) single-voxel localization. Data were acquired from 2 × 2 × 2 cm3 voxels, with a repetition time of 1 s and 128 averages (standard acquisition) or 256 averages (DQ-filtered acquisition), requiring 2.15 and 4.3 min respectively. Of 37 evaluated data pairs, 20 cases (54%) had measureable lactate (fitted Cramer–Rao lower bounds ≤ 20%) in either the DQ-filtered or the standard acquisition spectra. The measured DQ-filtered lactate signal was consistently downfield of lipid (1.33 ± 0.03 ppm vs 1.22 ± 0.08 ppm; p = 0.002), showing that it was not caused by lipid breakthrough, and that it matched the lactate signal seen in standard measurements (1.36 ± 0.02 ppm). In the absence of lipid, similar lactate concentrations were measured by the two methods (mean ratio DQ filtered/standard acquisition = 1.10 ± 0.21). In 7/20 cases with measurable lactate, signal was not measureable in the standard acquisition owing to lipid overlap but was quantified in the DQ-filtered acquisition. Conversely, lactate was undetected in seven DQ-filtered acquisitions but visible using the standard acquisition. In conclusion, the DQ filtering method has proven robust in eliminating lipid and permits uncontaminated measurement of lactate. This is important validation prior to use in tissues outside the brain, which contain large amounts of lipid and which are often susceptible to motion.

Background: The aim of this review was to examine whether the measurement of lactate in capillary blood samples using point-of-care handheld analysers corresponds sufficiently closely with arterial and venous whole-blood samples analysed by hospital central laboratory or blood gas analyser to be used interchangeably. Methods: A systematic search, informed by focused inclusion/exclusion criteria, was performed using multiple databases up to October 2015. A total of 65 articles were considered to have potential relevance and were evaluated in full text, of which ultimately five articles met all inclusion/exclusion criteria, and a final four were selected after data extraction and quality appraisal. Results and Conclusion: All four studies found a predominantly upward bias in the measurement of lactate in capillary samples tested using a handheld point-of-care device over arterial or venous samples tested by laboratory methods or blood gas analyser. In terms of correlation, there was consensus between the studies that the strength of association between the two methods of measurement was statistically significant. Three studies directly examined the extent of agreement between point-of-care capillary lactate measurements and those of laboratory or blood gas analyser reference determined to ±2 standard deviations; 95% confidence intervals, and report contextually broad limits of agreement, identifying a potential for both over triage and, to a lesser extent, under triage. The findings of the review do not support interchangeable use of handheld fingertip point-of-care lactate measurement with laboratory or blood gas analyser methods in the identification of sepsis.

Background and Aims: Hyperlactatemia at the time of admission is a documented risk factor for mortality in critically ill adult patients. However, the significance of lactate measurement at admission for mortality in critically ill children remains uncertain. This study evaluated the predictive value of blood lactate levels at the time of admission and determined the cut-off values for predicting in-hospital mortality in the critically ill children. Materials and Methods: A total of 60 children with diagnosis of sepsis admitted to PICU of a tertiary care hospital were included in the study. PRISM III score and demographic characteristics of all children were recorded. Serum lactate levels were measured at 0-3, 12 and 24 h of PICU admission. The outcome like survival or death was correlated with serum lactate levels. Results: Septic shock was the most common type of shock and had highest mortality. Lactate levels were significantly higher in non survivors in comparison to survivors. A lactate value of more than 5 mmol/l at 0-3, 12 and 24h of PICU admission had increased mortality. Conclusions: A high blood lactate level at admission is independently associated with higher in-hospital mortality in the critically ill children.

Second-line methods of foetal monitoring have been developed in an attempt to reduce unnecessary interventions due to continuous cardiotocography (CTG), and to better identify foetuses that are at risk of intrapartum asphyxia. Very few studies directly compared CTG with foetal scalp blood (FBS) and CTG only. Only one randomised controlled trial (RCT) was published in the 1970s and had limited power to assess neonatal outcome. Direct and indirect comparisons conclude that FBS could reduce the number of caesarean deliveries associated with the use of continuous CTG. The main drawbacks of FBS are its invasive and discontinuous nature and the need for a sufficient volume of foetal blood for analysis, especially for pH measurement, resulting in failure rates reaching 10%. FBS for lactate measurement became popular with the design of test-strip devices, requiring0.5 mL of foetal blood. RCTs showed similar outcomes with the use of FBS for lactates compared with pH in terms of obstetrical interventions and neonatal outcomes. In conclusion, there is some evidence that FBS reduces the need for operative deliveries. However, the evidence is limited with regard to actual standards, and large RCTs, directly comparing CTG only with CTG with FBS, are still needed.

Background In the Emergency Department, lactate measurement is a useful tool to risk-stratify critically ill patients. However, it is unclear whether arterial or peripheral venous lactate levels can be used interchangeably for this purpose. In this systematic review, we provide an overview of studies investigating the agreement between arterial and peripheral venous lactate levels in the Emergency Department. Methods PubMed, Embase, the Cochrane Central Register of Controlled Trials/Wiley, Web of Science/Clarivate Analytics, and references of selected articles were assessed for all studies comparing arterial and peripheral venous lactate levels in adult patients in the emergency department. Two reviewers independently screened all potentially relevant titles and abstracts for eligibility using a standardized data-worksheet. Results Nine studies were included. Peripheral venous lactate levels tend to be higher than arterial lactate levels with mean differences ranging from 0.18 mmol/l to 1.06 mmol/l. Importantly, poorer agreement occurs in hyperlactatemia. At a cut-of level of 1.6 mmol/l, peripheral venous lactate can rule out arterial hyperlactatemia with a sensitivity between 94% and 100%. At a cut off value of 2 mmol/l, sensitivities of 97% and 100% were found. Conclusion Agreement between arterial and peripheral venous lactate is poor in hyperlactatemia, making peripheral venous lactate an unreliable parameter to use interchangeably in the ED. In clinical practice, peripheral venous lactate can be used as a screening tool to rule out arterial hyperlactatemia at a cut-off value of 2 mmol/l. However, hyperlactatemia should be confirmed using arterial sampling in case of a peripheral venous lactate level > 2 mmol/l.

Background Blood gas analysis and blood lactate measurement have important roles in patient management. Point-of-care (POC) testing simplifies and provides rapid blood gas and lactate measurements. This study aimed to compare pH, pCO2 , pO2 , and lactate measurements between a POC device and a benchtop blood gas analyzer typically used in a hospital central laboratory, and to evaluate the inter-device variability of the POC device. Methods A cross-sectional study was conducted with a sample size of 100. Each sample was measured for pH, pCO2 , pO2 , and lactate using a Nova pHOx plus L® benchtop blood gas analyzer in the central laboratory and an i-STAT® handheld POC device. The results of both devices were compared using Pearson or Spearman correlation coefficients and Bland-Altman tests. Testing of the inter-device variability was done by using three different i-STAT® devices, and the results were compared statistically. Results Strong correlations were observed for all test results. In Bland-Altman analysis, ≥95% of the results were within the limits of agreement, with the exception of lactate, which had only 93%. The results that were beyond the limits were primarily lactate levels >8 mmol/L. Biases between the benchtop analyzer and the i-STAT® were not clinically significant, except pH. No significant inter-device variability was observed between the i-STAT® analyzers. Conclusion This comparison study of pH, pCO2 , pO2 , and lactate measurements between Nova pHOx plus L® and i-STAT® analyzers showed good agreement. However, lactate measurement results >8 mmol/L on the i-STAT® analyzer should be interpreted with caution.

Objectives Deviation from manufacturers’ pre-analytical sample handling recommendations necessitates extensive validation studies. This report uses plasma lactate testing, where a recommended 15 min room temperature sample handling limit cannot be met by the clinical laboratory, as an example for studies to bridge the gap with practice. Design and Methods Triplicate blood samples were collected from patients (n = 51) with lactate requests by clinicians and from normal volunteers (n = 50). One tube was transported on ice (4 °C), the others were maintained at room temperature (23 °C). Tubes stored at 4 °C were processed at 30 min from collection. Tubes stored at 23 °C were processed at 15 and at 30 min from collection. Lactate levels were measured using Roche Diagnostics Cobas 6000® analyzer. Results Lactate levels in normal subjects ranged from 0.6 to 3.1 mmol/L (median 1.1). Patient lactate levels ranged from 0.8 to 26.3 mmol/L (median 2.2). Bias in lactate levels following extended storage of samples from both normal subjects and patients ranged from − 1.3 to2.2 and from − 1.0–1.0 mmol/L when stored for 30 min at 23 °C or at 4 °C, respectively. The bias between lactate levels at 30 min at 23 °C and 4 °C was − 1.2 to − 0.5 mmol/L for both populations. Although the bias was not statistically significant for all variables, a clinically significant (>0.2 mmol/L) bias was observed in 28% of normal and 7.0% of patient samples. Conclusion Extending the pre-analytical time to 30 min at 23 °C did not significantly impact clinical utility of lactate measurement in our patient population., Highlights • Pre-analytical gaps exist between manufacturers’ recommendation and clinical practice. • Sample handling time for lactate testing was extended to reflect clinical practice. • Normal subjects, often preferred, showed high variability compared to patients. • Patient samples must always be included in pre-analytics studies. • Doubling handling time at 23 °C did not have significant clinical impact.

BACKGROUND: Lactate clearance has been developed into a marker of resuscitation in trauma, but no study has compared the predictive power of the various clearance calculations. Our objective was to determine which method of calculating lactate clearance best predicted 24-hour and in-hospital mortality after injury. STUDY DESIGN: Retrospective chart review of patients admitted to a Level-1 trauma center directly from the scene of injury from 2010 to 2013 who survived >E15 min, had an elevated lactate at admission (≥3 mmol/L), followed by another measurement within 24 h of admission. Lactate clearance was calculated using five models: actual value of the repeat level, absolute clearance, relative clearance, absolute rate, and relative rate. Models were compared using the areas under the respective receiver operating curves (AUCs), with an endpoint of death at 24 h and in-hospital mortality. RESULTS: 3910 patients had an elevated admission lactate concentration on admission (mean = 5.6 ± 3.0 mmol/L) followed by a second measurement (2.7 ± 1.8 mmol/L). Repeat absolute measurement best predicted 24-hour (AUC = 0.85, 95% CI: 0.84–0.86) and in-hospital death (AUC = 0.77; 95% CI, 0.76–0.78). Relative clearance was the best model of lactate clearance (AUC = 0.77, 95% CI: 0.75–0.78 and AUC = 0.705, 95% CI: 0.69–72, respectively) (p < 0.0001 for each). A sensitivity analysis using a range of initial lactate measures yielded similar results. CONCLUSIONS: The absolute value of the repeat lactate measurement had the greatest ability to predict mortality in injured patients undergoing resuscitation.

Objective To establish a reference interval for plasma lactate in a population of healthy adult cats on a laboratory analyzer (Nova Biomedical Critical Care Xpress [CCX]) and 2 commercially available point-of-care (POC) analyzers (Abbott i-STAT [i-STAT] and Nova Biomedical Lactate Plus [LP]), and to compare the level of agreement of lactate measurement between the laboratory analyzer and POC analyzers. Design Prospective observational study. Setting University veterinary teaching hospital. Animals Forty-seven healthy adult cats. Interventions Jugular phlebotomy. Measurements and Main Results In this population, plasma lactate reference interval was 0.67–5.44 mmol/L for the CCX, 0.65–5.16 mmol/L for the i-STAT, and 0.68–4.39 mmol/L for the LP. Comparisons were made between lactate measurements on 2 point-of-care analyzers and the laboratory analyzer using the Bland–Altman method. For the comparison of CCX and i-STAT, the bias was −0.10 mmol/L; for the CCX and LP, the bias was −0.24 mmol/L. Conclusions Measurements of plasma lactate in cats using the i-STAT showed acceptable agreement with the CCX. The LP showed weaker agreement. However, both POC analyzers are suitable for measurement of lactate in cats, provided results from different POC analyzers are not directly compared. This study identified a larger reference interval for plasma lactate concentration in cats than what has been previously reported.

Background Blood lactate is a marker of patient illness severity. Capillary lactate (CAP-LACT) measurement can potentially improve patient screening; however, it has poor evidence of clinical utility. Aim We aimed to investigate agreement between CAP-LACT and peripheral venous lactate (PV-LACT). Methods We performed a prospective observational pilot study of 99 patients requiring lactate measurement. Paired CAP-LACT and PV-LACT was recorded. Agreement was determined by Bland-Altman analysis. Results Bias was 0.2 mmol/L, with 95% limits of agreement from −1.9 to 2.3. Conclusions CAP-LACT has poor agreement with PV-LACT. Further research is needed to improve its potential clinical utility.

To investigate the utility of umbilical artery (UA) lactate measurements in a South African hospital for assessing intrapartum care and predicting neonatal outcomes.From 3 March-12 November 2014, we conducted a prospective cohort study of UA lactate levels at Kalafong Hospital, Pretoria, South Africa. Following birth, a UA blood sample (0.5uL) was taken from a double-clamped segment of cord and the lactate measured. Maternal and neonatal characteristics and outcomes were recorded.During the study, there were 4668 deliveries; including 1091 emergency cesarean and 154 instrumental deliveries. A lactate was recorded for 946 deliveries (20.3%). 190 babies required neonatal resuscitation, with an optimal cutoff for lactate of 5.45 mmol/L (sensitivity 68%, specificity 72%). 124 babies required nursery admission with the optimal cutoff for lactate 4.95 mmol/L (sensitivity 61%, specificity 59%). 55 babies had an Apgar score7 at 5 min and the optimal lactate for this outcome was 5.65 mmol/L (sensitivity 64%, specificity of 69%).Umbilical lactate can be used in a middle-low resource setting as a measurement of intrapartum hypoxia, with reasonable sensitivity and specificity for the prediction of, or need for, resuscitation, admission to the nursery, and low Apgar scores.

Objective: Lactate is a significant marker of critical illness and mortality in sepsis and trauma patients. The purpose of this study is to evaluate point-of-care lactate testing by paramedics in a UK ambulance service. Methods: Selected enhanced care paramedics were trained to use the lactate meter in patients with suspected sepsis and patients who trigger the major trauma bypass protocol. Feedback was collected on the practicalities of using the meter and the potential impact on the diagnosis of sepsis. Results: Data were collected on 114 patients, 96% had suspected sepsis (n=109) and 4% (n=5) were patients who had sustained trauma. The participants found that the ability to take lactate readings was useful and increased their confidence in their clinical decision making. Conclusions: Point-of-care lactate measurement is feasible in pre-hospital care and appears to support paramedics in their decision making.

Increasingly, smartphones are used as portable personal computers, revolutionizing communication styles and entire lifestyles. Using 3D-printing technology we have made a disposable minicartridge that can be easily prototyped to turn any kind of smartphone or tablet into a portable luminometer to detect chemiluminescence derived from enzyme-coupled reactions. As proof-of-principle, lactate oxidase was coupled with horseradish peroxidase for lactate determination in oral fluid and sweat. Lactate can be quantified in less than five minutes with detection limits of 0.5 mmol L(-1) (corresponding to 4.5 mg dL(-1)) and 0.1 mmol L(-1) (corresponding to 0.9 mg dL(-1)) in oral fluid and sweat, respectively. A smartphone-based device shows adequate analytical performance to offer a cost-effective alternative for non-invasive lactate measurement. It could be used to evaluate lactate variation in relation to the anaerobic threshold in endurance sport and for monitoring lactic acidosis in critical-care patients.

Objective To determine if absolute plasma lactate concentration or lactate clearance in dogs with septic peritonitis is associated with morbidity or mortality. Design Retrospective cohort study from 2007 to 2012. Setting University teaching hospital. Animals Eighty-three dogs with septic peritonitis were included. Patients had at least 1 plasma lactate measurement during the course of the hospitalization. Results Sixty-four percent of the patients survived to discharge, 22% were euthanized, and 14% died during hospitalization. Plasma lactate concentration >2.5 mmol/L on admission (29% of the patients) was associated with mortality (P = 0.001). Median admission plasma lactate concentration (n = 81) was significantly different between nonsurvivors (2.5 mmol/L, range 0.5–8.4) and survivors (1.4 mmol/L, range 0.5–9.7; P = 0.007). Admission plasma lactate concentration >4 mmol/L yielded a sensitivity of 36% and a specificity of 92% for nonsurvival. The inability to normalize plasma lactate concentration within 6 hours of admission (n = 10/24) yielded a sensitivity of 76% and specificity of 100% for nonsurvival. Postoperative hyperlactatemia (plasma lactate concentration >2 mmol/L; n = 18/76) had a sensitivity of 46% and specificity of 88% for nonsurvival. Persistent postoperative hyperlactatemia (n = 11/18) had a sensitivity of 92% and a specificity of 100% for nonsurvival. Lactate clearance less than 21% at 6 hours (n = 20) had a sensitivity of 54% and specificity of 91% for nonsurvival. Lactate clearance less than 42% at 12 hours (n = 18) had a sensitivity of 82% and a specificity of 100% for nonsurvival. Conclusions Admission plasma lactate concentration and lactate clearance were good prognostic indicators in dogs with septic peritonitis.

Lactate measurement is vital in clinical diagnostics especially among trauma and sepsis patients. In recent years, it has been shown that saliva samples are an excellent applicable alternative for non-invasive measurement of lactate. In this study, we describe a method for the determination of lactate concentration in saliva samples by using a simple and low-cost cotton fabric-based electrochemical device (FED). The device was fabricated using template method for patterning the electrodes and wax-patterning technique for creating the sample placement/reaction zone. Lactate oxidase (LOx) enzyme was immobilised at the reaction zone using a simple entrapment method. The LOx enzymatic reaction product, hydrogen peroxide (H2O2) was measured using chronoamperometric measurements at the optimal detection potential (-0.2 V vs. Ag/AgCl), in which the device exhibited a linear working range between 0.1 to 5 mM, sensitivity (slope) of 0.3169 μA mM(-1) and detection limit of 0.3 mM. The low detection limit and wide linear range were suitable to measure salivary lactate (SL) concentration, thus saliva samples obtained under fasting conditions and after meals were evaluated using the FED. The measured SL varied among subjects and increased after meals randomly. The proposed device provides a suitable analytical alternative for rapid and non-invasive determination of lactate in saliva samples. The device can also be adapted to a variety of other assays that requires simplicity, low-cost, portability and flexibility.