Prehospital Lactate Meters
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DrankTheKoolaid
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Trying to form one myself for the NorCal region to at least do a trial.
San Diego has a trial going for POC lactate but it is specific for shock related to trauma. You can read about it on CaEMSA website. If and when i get ours up Ill post info here
San Diego has a trial going for POC lactate but it is specific for shock related to trauma. You can read about it on CaEMSA website. If and when i get ours up Ill post info here
TransportJockey
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The service I worked for in the Denver Metro (ActionCare Ambulance) had them in their trucks that ran 911.
LondonMedic
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What would you do with that information?
How would you know that the lactate is from sepsis and not from, say, mesenteric infarction or metformin?
How would you know that the lactate is from sepsis and not from, say, mesenteric infarction or metformin?
I was trying to figure that out myself...
Christopher
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You use it coupled with the SIRS criteria to perform a Sepsis Alert / Code Sepsis protocol, which would help drive early goal directed therapy. The Denver Alert Protocol saw pretty significant decreases in mortality after its implementation:
- Suspected or documented infection
- Age > 18 years
- Not Pregnant
- Two or more of the following: Temp >100.3F or <96.8F, Pulse > 90, RR > 20
- Hypoperfusion as indicated by at least one: BP < 90, MAP < 65, or Lactate >= 4
Patients with cryptic septic shock may have relatively normal vital signs, except they will have an elevated lactate.
If the patient is symptomatic, aren't you going to initiate treatment anyways for the BP, HR and RR?
If the vital signs are normal, are you going to do a lactate level on everyone over the age of 18 and not pregnant?
LondonMedic
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Why would you not already be resuscitating them?
True. But in these patients, would people actually measure lactates (they're well aren't they)? How are you determining that this is sepsis as opposed to anything else?
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No one said we wouldn't be. Some systems call Sepsis alerts much like a STEMI alert to get the ball rolling at the hospital prior to actually arriving there. Get pharmacy, an intensivist, an ICU nurse or two, lab along with others that I'm missing up and at 'em and into the ER waiting rather than playing the "paging" game and waiting for people.
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LondonMedic
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How :censored::censored::censored::censored: are your EDs?
Christopher
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Even high performing PCI centers do poorly on First Medical Contact to Balloon times without prehospital alert systems for STEMI. Sepsis Alert programs provide the same thing for septic patients.
You get the reduction in mortality as the patient has been pre-screened for the ED. All they do now is grab the sepsis-bundle and begins their workup. Follow-thru to the ICU or floor becomes seamless as the system of care is already in place and activate. In a busy healthcare system this keeps patients from falling through the cracks. In any healthcare system it helps to ensure a consistent level of care and QA/QI.
You're kidding? To initiate treatment on a suspected sepsis patient? Most ERs should have STAT lab capability and alot of ER docs now how to start treatment since the guidelines are posted everywhere and there has been a major push in the hospitals for this over the past 10 years. That sounds like your ER doctors aren't at par with others if they don't know how to start treating a sepsis patient. Can't they start central lines or intubate without an intensivist? Why would an ICU nurse need to be there? The Sepsis Bundle is great and can easily be followed with others brought into but not a big production like what seems to be suggested.
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When you have 4 hospitals serving a population of > 500k with one being a Level II trauma center and one of those hospitals is a band-aid station and another isn't much better things get a bit hectic at times.
We don't call sepsis alerts in my system. I was just giving an example. I think it's pretty bold of you to say our ERPs are sub-par without knowing the system I work in or the hospitals that we work with. We have an excellent, more than capable group of Emergency Physicians in our area. Yes they can intubate and start central lines but you know they are going to be looking for a consult not long after that and with busy ICUs sometimes that can take a while.
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We have big hospitals also. Most of our LTC patients we transport either routine or 911 will probably have an elevated lactate level. They get screened and are treated accordingly. I can't imagine calling an alert for every nursing patient which could easily be up to 50 before lunch by your criteria. Many will be treated without any problems. I can't see having a dozen people running into an ER everytime there is any kind of alert which at a busy place, just trauma, stemi and stroke can be dozens of times a day. Your description of the hospital ER reminds me of one of those cartoons with the crowd running in and out of door everytime a sign blinks.
LondonMedic
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Is that high or low?
Here, for example, we have roughly one ED per 250,000 residents.
London has 30 hospitals for a population of 7,000,000 (almost doubling between 9 and 5 Mon-Fri during the summer) of which four are trauma centres).
Your initial description gave a piss poor view of your ER and its doctors as if they needed the intensivist to get the party started.
LondonMedic
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But you would want them to not do their emergency physician bit and hand over care to intensivists because of a random number generator on your ambulance?
Do they not even get to play with their 'GuessTheLactate' machine?
badly, for a number of reasons.
Aidey
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Apparently it is gang up on Rob day today. :glare:
JakeEMTP, your attitude is offensive. Either give us a good explanation for your high and mighty attitude or knock it off. Veneficus has more education than 1/2 of us put together, which gives him the right to have an attitude sometimes. You on the other hand are coming off as a jerk.
Lactate monitors are meant to be used in conjunction with other assessment findings and patient history to determine likelihood that the pt is septic. This is not hugely different from how we use 12 leads. Given the huge variances between hospital capabilities some of them benefit from being forewarned about a potential sepsis patient. Its great that you think most hospitals have stat lab capability, but until most hospitals do, it doesn't matter what you think.
There is increasing evidence that the earlier sepsis is caught and fluid resuscitation is initiated the better the pt outcome. Sepsis is assocaited with high morbidity and mortality rates so an effort to decrease those rates is a good thing. As Denver showed, early identification correlated with a decreased mortality.
The criteria that Christopher posted are not something he just came up with. They are widely accepted criteria for SIRS. If you guys think it is such a horrible idea, feel free to argue that with the hospitals and EMS systems already doing it, and see how far you get.
Why are CVA, AMI and trauma alerts ok, but sepsis alerts aren't?
JakeEMTP, your attitude is offensive. Either give us a good explanation for your high and mighty attitude or knock it off. Veneficus has more education than 1/2 of us put together, which gives him the right to have an attitude sometimes. You on the other hand are coming off as a jerk.
Lactate monitors are meant to be used in conjunction with other assessment findings and patient history to determine likelihood that the pt is septic. This is not hugely different from how we use 12 leads. Given the huge variances between hospital capabilities some of them benefit from being forewarned about a potential sepsis patient. Its great that you think most hospitals have stat lab capability, but until most hospitals do, it doesn't matter what you think.
There is increasing evidence that the earlier sepsis is caught and fluid resuscitation is initiated the better the pt outcome. Sepsis is assocaited with high morbidity and mortality rates so an effort to decrease those rates is a good thing. As Denver showed, early identification correlated with a decreased mortality.
The criteria that Christopher posted are not something he just came up with. They are widely accepted criteria for SIRS. If you guys think it is such a horrible idea, feel free to argue that with the hospitals and EMS systems already doing it, and see how far you get.
Why are CVA, AMI and trauma alerts ok, but sepsis alerts aren't?