I read the article by McLean et al (1) on "Investigating sepsis with biomarkers" with interest, especially with the role of lactate measurement. Whilst the authors note lactate itself is not a diagnostic tool it has a far more useful role in risk stratifying and prognosticating the septic and non-septic patient alike (2), and so has a recommendation to be measured on presentation in the Surviving Sepsis Guidelines (3) as well as the Sepsis Six bundles (4). It would have been worthwhile to have emphasised this in the article. Furthermore the use of point-of-care lactate machines in the emergency department, as well as in critical care, allows us access to and act upon lactate results within minutes without having to wait for formal laboratory results to return, a benefit over many of the other biomarkers mentioned.
I would also suggest that the authors note on Jones et. al's randomised control trial (5) not confirming the recommendation in using lactate clearance as a therapeutic endpoint misses an important message in the article. Jones et al. noted that lactate clearance as a measurement was non-inferior to ScvO2, which has important implications as many septic patients are not treated in critical care where ScvO2 can be measured (6). This allows us to easily measure response to treatment at ward level for this important group of patients. Serial lactate measurement can give clinicians an idea if treatment is effective and can be continued, or if modifications to management need to be considered. However further studies are needed to clarify what magnitude of lactate clearance is optimal (7).
I congratulate the authors on this excellent article, and I hope that my letter trying to emphasise the importance of lactate measurement in the acute management of sepsis stimulates some debate.
Yours Faithfully
Deepankar Datta
Emergency Medicine trainee, Emergency Medicine Research Group Edinburgh
MBChB BSc(Hons) MCEM
References
(1) McLean AS, Tang B, Huang SJ. Investigating sepsis with biomarkers, 2015, BMJ 2015;350:h254. doi: 10.1136/bmj.h254
(2) Datta D, Walker C, Gray AJ, Graham C. Arterial lactate levels in an emergency department are associated with mortality: a prospective observational cohort study. Emerg Med J 2015. doi:10.1136/emermed-2013-203541
(3) Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 2013;39:165-228.
(4) Daniels R, Nutbeam T, McNamara G, Galvin C. The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study. Emerg Med J. 2011 Jun;28(6):507-12. doi: 10.1136/emj.2010.095067
(5) Jones AE, Shapiro NI, Trzeciak S, Arnold RC. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy—a randomized control trial. JAMA 2010;303:739-46.
(6) Gray AJ, Ward K, Lees F, Dewar C, Dickie S, McGuffie C. STAG steering committee, The epidemiology of adults with severe sepsis and septic shock in Scottish emergency departments., Emerg Med J. 30 (5) (2013) 397–401.
(7) Walker CA, Griffith DM, Gray AJ, et al. Early lactate clearance in septic patients with elevated lactate levels admitted from the emergency department to intensive care: time to aim higher? Journal of Critical Care 2013;28:832–7. doi:10.1016/j.jcrc.2013.02.004
Competing interests:
No competing interests
04 February 2015
Deepankar Datta
Emergency Medicine trainee
Emergency Medicine Research Group Edinburgh
Emergency Department, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, EH16 4SA, United Kingdom
Rapid Response:
Dear Sir/Madam
I read the article by McLean et al (1) on "Investigating sepsis with biomarkers" with interest, especially with the role of lactate measurement. Whilst the authors note lactate itself is not a diagnostic tool it has a far more useful role in risk stratifying and prognosticating the septic and non-septic patient alike (2), and so has a recommendation to be measured on presentation in the Surviving Sepsis Guidelines (3) as well as the Sepsis Six bundles (4). It would have been worthwhile to have emphasised this in the article. Furthermore the use of point-of-care lactate machines in the emergency department, as well as in critical care, allows us access to and act upon lactate results within minutes without having to wait for formal laboratory results to return, a benefit over many of the other biomarkers mentioned.
I would also suggest that the authors note on Jones et. al's randomised control trial (5) not confirming the recommendation in using lactate clearance as a therapeutic endpoint misses an important message in the article. Jones et al. noted that lactate clearance as a measurement was non-inferior to ScvO2, which has important implications as many septic patients are not treated in critical care where ScvO2 can be measured (6). This allows us to easily measure response to treatment at ward level for this important group of patients. Serial lactate measurement can give clinicians an idea if treatment is effective and can be continued, or if modifications to management need to be considered. However further studies are needed to clarify what magnitude of lactate clearance is optimal (7).
I congratulate the authors on this excellent article, and I hope that my letter trying to emphasise the importance of lactate measurement in the acute management of sepsis stimulates some debate.
Yours Faithfully
Deepankar Datta
Emergency Medicine trainee, Emergency Medicine Research Group Edinburgh
MBChB BSc(Hons) MCEM
References
(1) McLean AS, Tang B, Huang SJ. Investigating sepsis with biomarkers, 2015, BMJ 2015;350:h254. doi: 10.1136/bmj.h254
(2) Datta D, Walker C, Gray AJ, Graham C. Arterial lactate levels in an emergency department are associated with mortality: a prospective observational cohort study. Emerg Med J 2015. doi:10.1136/emermed-2013-203541
(3) Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 2013;39:165-228.
(4) Daniels R, Nutbeam T, McNamara G, Galvin C. The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study. Emerg Med J. 2011 Jun;28(6):507-12. doi: 10.1136/emj.2010.095067
(5) Jones AE, Shapiro NI, Trzeciak S, Arnold RC. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy—a randomized control trial. JAMA 2010;303:739-46.
(6) Gray AJ, Ward K, Lees F, Dewar C, Dickie S, McGuffie C. STAG steering committee, The epidemiology of adults with severe sepsis and septic shock in Scottish emergency departments., Emerg Med J. 30 (5) (2013) 397–401.
(7) Walker CA, Griffith DM, Gray AJ, et al. Early lactate clearance in septic patients with elevated lactate levels admitted from the emergency department to intensive care: time to aim higher? Journal of Critical Care 2013;28:832–7. doi:10.1016/j.jcrc.2013.02.004
Competing interests: No competing interests