Wednesday, January 22, 2020

Don't give fluids just because the lactate is elevated.

Lactate is elevated? (without assessing the patient) Give a fluid bolus.

Wait, WHAT?!?!? Whyyyy? 😫

This is something I routinely see today. I routinely saw it at the Ivory Tower where I trained in fellowship. I routinely did it myself when I was a young whipper snapper of a resident and didn't know any better. Now, I'm here to tell you that you can do better.

I don't blame you for doing this, though. You've seen other clinicians do it. You were likely trained this way. The nurses have been trained this way. When the lactate is elevated, page the doctor and expect an order for a fluid bolus. It makes one feel all warm and fuzzy inside like "I did something". Everyone pats themselves on the back. Well I'm here to tell you that from now on, every time you do that, you're more likely to be wrong in your management that right.

This article which describes the "lacto-bolus reflex", i.e. to give a bolus of fluid for every elevated lactate. The authors are just as fed up about it as I am. IV fluid boluses are not benign. Fortunately, this article is completely free (I like finding you all full free articles) and it describes why the whole idea of patients developing a lactic acidosis due to cells not getting oxygen hypoperfusion is silly to the point where many of us need to be re-educated. I will admit, I had to be re-educated myself. I was not born knowing this stuff. I used to do it wrong. Now I'm trying to do it right.

The article is easy to read, for those of you who choose to dive further into it. Ultimately, they conclude that, although lactate levels are helpful for prognosis (plenty of data on that), and lactate not going away is helpful to know whether you have control of your patient or not, it ultimately does not help in any way, shape, or form, to guide fluid resuscitation. A 🎩 tip to the authors.

-EJ



Link to Article

Link to FULL FREE PDF

Spiegel R, Gordon D, Marik PE. The origins of the Lacto-Bolo reflex: the mythology of lactate in sepsis. J Thorac Dis 2020;12(Suppl 1):S48-S53.

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