Lactate Monitoring in Critically Ill Patients

The resident internal medicine called from the Emergency Department (ED). “Can you please come and see my patient, I think he is becoming septic and needs admission to the intensive care”. In the ED we found a confused older patient with an oxygen mask who was clearly dyspnoeic, the urinary catheter was filled with a dark brown fluid, the collecting bag was empty. The resident reported that he admitted the patient 4 hours earlier as he suspected pneumonia. On admission the patient was hypoxic but this clearly improved with the supplemental oxygen. The resident was still waiting for all the laboratory results and the chest X-ray. However, now that the patient had developed hypotension he thought the patient was clearly at risk and intensive care admission was required. When we asked why he had not called us earlier, he replied that he intended to admit the patient to the general ward as he was haemodynamically stable and oxygenation had improved on supplemental oxygen so intensive care admission was not required. When reviewing the blood sample that was drawn 30 min following presentation, besides hypoxaemia, an increased lactate level of 4.6 mmol/l was present. The resident pointed out that hyperlactataemia in sepsis is not related to tissue hypoxia but rather is a marker of increased aerobic metabolism. Therefore he thought there was no need to react to this hyperlactataemia. In this case presentation the presence of hyperlactataemia did not result in treatment consequences. When having read this thesis the reader should be able to indicate whether the resident was right or wrong in this decision. The general aim of this thesis is to evaluate the clinical value of blood lactate monitoring by assessing various aspects of lactate monitoring, including aetiology, the prognostic value and the impact on clinical outcome when incorporating lactate measurement in a treatment algorithm at the bedside. As the process of obtaining informed consent for participation in research is challenging in intensive care patients due to the emergency nature of critical illness, the secondary aim of this thesis is to evaluate consent procedures in emergency critical care research.

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