Prehospital Lactate Meters

[socalmedic]

I will try to locate the study I read last year, but it stated that lactate can be affected by as much as 1 mmol/l after the first liter of NaCl. making POC testing prior to admin useful for trending.

as for accuracy and usability of the POC direct your attention to this study,
http://www.ncbi.nlm.nih.gov/pubmed/11167165
comparing the speed, cost, and accuracy of POC verses central laboratory.

 

[ffemt8978]

This is for everyone in this thread:

Play nice, or become the focus of my complete and undivided attention.

 

[JakeEMTP]

Some of the studies done in the US and Canada were blind studies. The Paramedics did not treat by the number on the lactate monitor. They treated by their protocols for suspected sepsis. That was what was actually shown to be effective and not the number on the meter. Better assessment skills are the most important and the gadget may just be there to confirm what you have assessed the problems to be.

Also, for Denver EMS, their protocols with a Jan 2012 update has this to say:

Lactate Measurement
At this time there is insufficient evidence to recommend for or against routine point of care measurement of lactate by EMS. Although it shows promise for improved detection of hypoperfusion, lactate measurement is not considered mandatory or standard of care by the Denver Metro EMS Medical Directors. Its use will be governed by individual agency Medical Director policy.

http://www.dmemsmd.org/sites/default/files/Denver Metro Protocols - 12_13_11.pdf

This is found in protocol 4060 Medical Hypotension Shock Protocol.

Don't forget the 100% facemask at 15 L/Min.

 

[ah2388]

Obtaining a medical record or just a brief summary or face sheet doesn't always cut it.

How many cartridges are you going to carry with you POC machine? How will you store them? Will you have them ready for all 911 calls?

How will it change what you do to treat your patient? Will you be able to do blood cultures on the first stick and will the hospital trust them? Most prefer to draw their own cultures. What about all of the other cultures and lab work that goes with a sepsis diagnosis? Just one or two lab values are only a small part of the story. It is like a pulse ox SpO2. It is just one number and not really adequate to tell how the organs are perfusing.

Think about all of the factors involved.

Critical Thinking can be applied but to be effective you have the education to utilize the data you are gathering from all of the new gadgets. I think I already said this when another person wanted iSTATs on every EMS truck. What will it change?

Chances are if you are bringing a sick patient to an ER from a nursing home a long distance, the staff or even physician will have called in some lab values and a report to the ER.

Alot of places are trying to stop duplication of services which are costly and painful. It is not about more skills on your resume but whether you actually change how you can treat a patient. Doing stuff that will be repeated again and again in the hospital probably isn't the best idea. We already have protocols for BP and HR. If you can't give a more detailed description of your patient to get across the idea the patient is sick, more gadgets isn't going to do you any good.

I was not advocating for drawing labs, nor was I advocating that a brief Hx was "adequate." I was simply stating that given the idea that drawing labs is not a difficult thing to teach, and would be simple to do in the field, it could be done without "hanging out on scene" for a prolonged period.

Regarding blood cultures, I dont see the reason they could not be drawn prehospital, so long as the procedure was performed using accepted guidelines from the various laboratory regulatory agencies.

I would tend to agree with some other posts in this thread advocating that we do better with the tools that we have, specifically in the area of educational requirements etc.

To summarize, I think that a very small population of patients might benefit from paramedics using this tool in a very small percentage of systems. I base that on nothing more than intuition, which I recognize is a poor indicator. This concept certainly deserves more exploration, and I would venture to say that exploring concepts which may benefit our patients, especially exploration specific to EMS, is extremely positive. While there have been some advances, I feel like EMS in some ways dead locked itself into certain ways of thinking, we have to evolve or we will die and exploration is a part of that.

 

[JakeEMTP]

I will try to locate the study I read last year, but it stated that lactate can be affected by as much as 1 mmol/l after the first liter of NaCl. making POC testing prior to admin useful for trending.

as for accuracy and usability of the POC direct your attention to this study,
http://www.ncbi.nlm.nih.gov/pubmed/11167165
comparing the speed, cost, and accuracy of POC verses central laboratory.

For trending how many times you want to stick a patient prehospital is a different matter. You should not use the same line you are infusing the blood in and that was pointed out in the Lactate Pro studies. If you already started fluids, another line or sample puncture at another site will have to be drawn. How many times you want to open a line in unfavorable situations is another consideration. Hospitals time their lab draws even in closed systems. In Exercise Phys Masters programs, athletes will have an arterial line for studies of lactate.

 

[Veneficus]

Don't want to get into any pissing match with you Vene. That is pointless. I've read some of your posts on other forums over the past 6 or 7 years. -_-

Am I that old?

I think this is the longest I have been on any forum, and even sometimes here cannot stand the simplicity.

 

[NYMedic828]

Am I that old?

I think this is the longest I have been on any forum, and even sometimes here cannot stand the simplicity.

Well, in all fairness you are at least a solid 7-10 years of studies ahead of 99% of us.

The main thing that drew me to and keeps me on this forum is that some people here are in fact so knowledgeable, many being RNs and a few of you being accomplished MDs.

It is refreshing and inspiring to receive help from those who don't forget where they come from rather than just leaving everyone else in the dust.

This thread seems to be getting into a pretty unnecessary battle. We are all here to share experiences and knowledge so that everyone may learn. Not fight with one another over something someone simply proposed as an idea.

 

[Christopher]

Regarding blood cultures, I dont see the reason they could not be drawn prehospital, so long as the procedure was performed using accepted guidelines from the various laboratory regulatory agencies.

We routinely draw labs enroute with every IV start at one of my services (hospital based, mean transport time of 7 minutes or so).

 

[NYMedic828]

We routinely draw labs enroute with every IV start at one of my services (hospital based, mean transport time of 7 minutes or so).

At my volunteer establishment I have the option to draw labs if I feel it would speed anything up and have the time to do it.

In NYC, paramedics are no longer permitted to routinely draw labs. The only time we are required/allowed to do it now is prior to the administration of hydroxocobalamin.

I think the main reason it was removed in NYC was to reduce the occurrence of accidental needle sticks.

 

[JakeEMTP]

Originally Posted by ah2388
Regarding blood cultures, I dont see the reason they could not be drawn prehospital, so long as the procedure was performed using accepted guidelines from the various laboratory regulatory agencies.

We routinely draw labs enroute with every IV start at one of my services (hospital based, mean transport time of 7 minutes or so).

If you are drawing blood cultures, what are you using to clean the site and how long are you allowing it to dry? How many culture specimen bottles are you drawing? Are you labeling with site, time, your name and delivering to the lab yourself? Where are you storing the specimen bottles in the ambulance and for how long before you throw them away? These are not the tubes and there is more involved.

 

[ffemt8978]

Several of the hospitals around here want the rainbow of tubes drawn on any patient with an IV. We had to get a variance from each hospital because our average transport time made most of them useless before we arrived.

 

[JakeEMTP]

Several of the hospitals around here want the rainbow of tubes drawn on any patient with an IV. We had to get a variance from each hospital because our average transport time made most of them useless before we arrived.

Were any of them the blood culture bottles? EMS fails in quality control and sometimes just puts doing a skill ahead of should it be done. Tubes aren't stored properly, not mixed properly after the draw, often mislabled if labeled at all, relying on nurses to label your draws, lack of IV practice with poor technique, multiple punctures after losing the IV while attempting to draw blood, not knowing anything about the tubes except for rainbow, broken tubes and a whole bunch of reasons. If the lab gets cited for a major medical error coming from one of those blood draws, the burden of your competency will be on them and showing proof of it. I doubt if many companies can pull up a lab draw education competency. The hospital won't have any defense and the EMS company can just say they were just told to draw these tubes. It would be the hospital's fault entirely for their good faith in the ambulance company or fire department.

This profession has a tendency to rush in and start doing something before the education. I think that applies to the things like CPAP, ETCO2, 12 leads, pulse oximetry, intubation, RSI, blood pressures and many of the medications if the posts here are any indication.

 

[Christopher]

If you are drawing blood cultures, what are you using to clean the site and how long are you allowing it to dry? How many culture specimen bottles are you drawing? Are you labeling with site, time, your name and delivering to the lab yourself? Where are you storing the specimen bottles in the ambulance and for how long before you throw them away? These are not the tubes and there is more involved.

I missed the "cultures" reference. We'll grab extra in 2 10cc syringes on occasion (aseptic w/ chloraprep; our start kits no longer include alcohol or iodine), but otherwise we're just drawing rainbows.

 

[Handsome Robb]

If you are drawing blood cultures, what are you using to clean the site and how long are you allowing it to dry? How many culture specimen bottles are you drawing? Are you labeling with site, time, your name and delivering to the lab yourself? Where are you storing the specimen bottles in the ambulance and for how long before you throw them away? These are not the tubes and there is more involved.

So you routinely walk all the way to the lab to deliver blood cultures? Sounds efficient.

The hospitals here use a pneumatic tube system to send labs and meds around the hospital. Even after all my clinical time I have never been to the lab at our Trauma Center.

We don't draw prehospital labs so I can't comment on that.

 

[Veneficus]

This profession has a tendency to rush in and start doing something before the education. I think that applies to the things like CPAP, ETCO2, 12 leads, pulse oximetry, intubation, RSI, blood pressures and many of the medications if the posts here are any indication.

I think there is validity to this statement.

It is rooted in the history of EMS though. The idea that minimally trained providers could offer "life saving skills."

I do not like many EMS practices or values. I have given up trying to change the industry. It is what it is. I just try to help advance the individual providers that are interested.

It does require dispelling a fair amount of dogma and propaganda though.

I have read here what is postulated about the Denver protocol.

I wonder if it is life saving because it helps in a system specific way or in a medical way?

But that will not be decided here.

But I think it is also important to realize that the shortcomings of US EMS is manifest in the poor pay, relatively few desirable positions, and complete lack of upper mobility.

No matter how good the medic, they will never move past being bound by rather limited protocol. I think that is one of the main reasons the really capable medics often move on from EMS at some point in their career.

At one point it was something seen as positive, but in the current climate, it seems anybody who betters themself is seen as elitist.

I know many very capable medics, but there is no denying medics are judged by the company they keep. For every one great one, there are hundreds of poor ones.

If any person here spent all their time hanging around with criminals of any sort, they would probably be stereotyped a criminal.

It has been some time since I had to point out that a large portion of the medical community has no respect for what EMS is or does.

It is up to the providers to change that. But the majority of them choose not to.

Even on this website, one of the most common questions of people resisting advancement and change is: "what is in it for me?"

I think the simple answer is "What do you put into it?"

Recognizing shortcomings is part of any profession. But it is not easy, particularly in EMS.

 

[socalmedic]

Update

here is the study I was talking about a few pages ago.

Decreasing Blood Lactate Levels in EMS Patients
By T. Ryan Mayfield, MS, NREMT-P; & Mary Meyers, MHA, EMT-P

Introduction: Research has shown that clearance of blood lactate is associated with better outcomes in patients with severe sepsis and septic shock. One of the primary treatments of these patients is administration of IV fluids. This study looked at blood lactate levels before and after EMS treatment to determine if there was a significant change.
Hypothesis: There will be a change in blood lactate levels between EMS and hospital lactate levels.
Methods: Paramedics were provided with and given training on the Lactate Pro blood lactate meter by Arkray Inc. This meter is FDA-approved and CLIA waived, and has shown a good correlation to hospital lactate tests. Between May 1, 2009, and Sept. 15, 2010, 134 patients with suspected severe sepsis or septic shock underwent blood lactate readings by EMS. Patients with a lactate reading of ≥ 4.0 mg/dL were considered to be in shock regardless of their corresponding blood pressure. Treatment was not dictated by this study and was administered according to EMS protocols.
Results : Of the 134 patients, 120 had hospital lactate levels available for comparison. Overall, hospital lactate levels were lower after EMS treatment. EMS patients were divided into groups that received greater than 1000 mL of fluid between readings (Group A), and patients who received between 250 mL and 1000 mL (Group B). Group A had a median decrease of 2.25 mg/dL (p = 0.0003) while Group B had a decrease of 1.1 mg/dL (p < 0.0001). Analysis used the Wilcoxon-Rank Sum Test.
Conclusions: There was a significant decrease in lactate levels associated with EMS treatment. Further, the group that received greater amounts of IV fluids had an even larger drop in lactate levels. These results illustrate the importance of EMS treatment and how it might impact patient outcomes. Further research and training needs to be done to expand the role of lactate in EMS, as well as reinforcing the importance of fluid administration to these patients.

sorry admin the only source I could find was copy and paste from the link below.

http://millhillavecommand.blogspot.com/2011/09/prehospital-sepsis-new-research.html

here is a link to a jems article about POC lactate.
http://www.emsworld.com/article/10319536/sepsis-alert

 

[systemet]

Can we lay off all the ad hominems, here? It's not helping us have a useful discussion. Jake obviously thinks paramedics are undereducated. If people disagree with that opinion, why not explain why, rather than calling him a troll?

I've used this guy (Accutrend Lactate), and it gives results in 60 seconds. No idea if it's FDA approved.

I think there was some evidence for a benefit on mortality from a European physician-based system, I'll try and take a look here.

I realise that a lot of people here work in systems where a long triage wait is 20 minutes, and there's a large number of centers with good ICUs. But not everyone does.

While I don't have evidence to support this (unless, I go look up that study that I'm not 100% certain about), I can see how screening for lactate could identify a higher risk subset of patients. This could be done quite quickly and cheaply in the ambulance, although I imagine you're going to lose some sensitivity and specificity using a cheap hand-held device versus the hospitals lab. It would be nice if these patients could avoid waiting in triage for a couple of hours, then going to a low acuity bed, and waiting for routine blood work to bring back a high lactate.

 

[ffemt8978]

Now that everyone has had a chance to come to their senses, and I've removed a lot of posts from this thread I've gone ahead and reopened it. If I have to get involved again, I will be handing out forum vacations.

 

[Handsome Robb]

Ok. So we all know that multiple things can cause an increase in lactate ranging from intense exercise all the way up to septic shock.

My question is why is it unreasonable for paramedics to be able to check a lactate level and use it, along with other clinical findings to help rule in/out sepsis and base their treatment off of it? I'm not advocating basing a treatment path off of a single number from a field lactate test. If we can get a POC lactate level prior to prehospital fluid administration, which will lower lactate levels, why not allow it? I know the hospital is going to do their own labs but would it not help the ER if we come in with a patient with suspected sepsis if we can pass on a lactate level prior to prehospital fluid administration? I'm not saying a "Sepsis Alert" is necessary but would us being able to pass on a lab value during our patient handoff that will help the hospital initiate early goal directed therapy and potentially life-saving interventions be a bad thing? Medicine is a team effort involving multiple specialties, including EMS. It's been stated multiple times in this thread: early fluid resuscitation and antibiotic administration reduce the mortality in septic patients, more specifically patients in septic shock.

We all know that prehospital medicine is not definitive care but isn't that part of our goal? To get the patient the definitive care and early goal directed directed therapy that they need? Does us being able to provide a lab value included in confirming a sepsis diagnosis not help that process? Maybe I'm totally off base here.

I'll agree that EMS education in the U.S. is severely lacking, there's no question about that but a lactate measurement is no more invasive than a CBG measurement. I'm not saying it's going to change our treatment prehospitally, what I am saying is it can/will aid the hospital in initiating early goal directed therapy while they wait for their own lab results to come back.

With all of the above said, the system I work in does not utilize prehospital lactate meters and we do not call sepsis alerts.

 

[LondonMedic]

My question is why is it unreasonable for paramedics to be able to check a lactate level and use it, along with other clinical findings to help rule in/out sepsis and base their treatment off of it?

Because, as been said at length and as you have just said, it's not a rule in/rule out test.

You've just said, that it won't change your management and it won't change the hospital's management.

You're entire argument for this new kit is that it would tell us something that might be interesting to know.