Hostname: page-component-cd9895bd7-gvvz8 Total loading time: 0 Render date: 2024-12-27T14:05:55.364Z Has data issue: false hasContentIssue false
  • English
  • Français

A 12-Month Clinical Audit Comparing Point-of-Care Lactate Measurements Tested by Paramedics with In-Hospital Serum Lactate Measurements

Published online by Cambridge University Press:  02 January 2018

Kristi L. Swan ,
Toby Keene  and
Bronwyn J. Avard
Kristi L. Swan
Affiliation:
Australian National University - Medical School, Acton, Australian Capital Territory, Australia Australian Capital Territory Ambulance Service, Majura, Australian Capital Territory, Australia
Toby Keene*
Affiliation:
Australian Capital Territory Ambulance Service, Majura, Australian Capital Territory, Australia Australian Catholic University, Canberra, Australia
Bronwyn J. Avard
Affiliation:
Canberra Hospital, Department of Intensive Care, Garran, Australian Capital Territory, Australia
*
Correspondence: Toby Keene, BSc, MPH ACT Ambulance Service GPO Box 158, Canberra City, Australia, 2601 E-mail: toby.keene@act.gov.au
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective

Prehospital point-of-care lactate (pLA) measurement may be a useful tool to assist paramedics with diagnosing a range of conditions, but only if it can be shown to be a reliable surrogate for serum lactate (sLA) measurement. The aim of this study was to determine whether pLA is a reliable predictor of sLA.

Methods

This was a retrospective study of adult patients over a 12-month period who had pLA measured by paramedics in an urban Australian setting and were transported by ambulance to a tertiary hospital where sLA was measured. Patients were excluded if they suffered a cardiopulmonary arrest at any time, had missing data, or if sLA was not measured within 24 hours of arrival. Levels of agreement were determined using methods proposed by Bland and Altman.

Results

A total of 290 patients were transported with a pLA recorded. After exclusions, there were 155 patients (55.0% male; age 71 [SD=18] years) remaining who had sLA recorded within 24 hours. Elevated pLA (>2.0mMol/L) was associated with sLA measurement (76.1% vs 23.9%; OR 3.18; 95% CI, 1.88-5.37; P<.0001). Median time between measurements was 89 minutes (IQR=75). Overall, median pLA was higher than sLA (3.0 [IQR=2.0] mMol/L vs 1.7 [IQR=1.3]; P<.001). Bland-Altman analysis on all participants showed a mean difference of 1.48 mMol/L (95% CI, -3.34 to 6.31). Normal pLA was found to be a true negative in 82.9% of cases, and elevated pLA was a true positive in 48.3% of cases. When the time between measurements was less than 60 minutes (n=25), normal pLA predicted normal sLA with 100% accuracy, with a false-positive rate of 18.2%. As time between measurements increased, accuracy diminished and the false-positive rate increased.

Conclusions

Overall, the level of agreement between pLA and sLA was poor. Accuracy of pLA diminished markedly as the time between the two measurements increased. It may be possible to use pLA as a screening tool; when considered this way, pLA performed much better, though larger prospective trials would be needed to confirm this.

SwanKL, KeeneT, AvardBJ. A 12-Month Clinical Audit Comparing Point-of-Care Lactate Measurements Tested by Paramedics with In-Hospital Serum Lactate Measurements. Prehosp Disaster Med. 2018;33(1):36–42.

Keywords

emergency medicineemergency services – ambulanceshocksevere sepsis
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 33 , Issue 1 , February 2018 , pp. 36 - 42
Copyright
© World Association for Disaster and Emergency Medicine 2017 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Footnotes

Conflicts of interest: The authors report no conflict of interest.

References

1. Bakker, J, Nijsten, MW, Jansen, TC. Clinical use of lactate monitoring in critically ill patients. Ann Intensive Care. 2013;3(1):12.CrossRefGoogle ScholarPubMed
2. Okorie, O, Dellinger, P. Biomarkers in critical illness: lactate: biomarker and potential therapeutic target. Crit Care Clin. 2011;27(2):299-326.CrossRefGoogle ScholarPubMed
3. Strnad, M, Lesjak, VB, Vujanovic, V, Pelcl, T, Krizmaric, M. Predictors of mortality and prehospital monitoring limitations in blunt trauma patients. Biomed Res Int. 2015: 1-7.CrossRefGoogle ScholarPubMed
4. Vandromme, MJ, Griffin, RL, Weinberg, JA, Rue, LW, Kerby, JD. Lactate is a better predictor than systolic blood pressure for determining blood requirement and mortality: could prehospital measures improve trauma triage? J Am Coll Surg. 2010;210(5):861-867.CrossRefGoogle ScholarPubMed
5. Williams, TA, Martin, R, Celenza, A, et al. Use of serum lactate levels to predict survival for patients with out-of-hospital cardiac arrest: a cohort study. Emerg Med Australas. 2016;28(2):171-178.CrossRefGoogle ScholarPubMed
6. Anderson, LW, Mackenhauer, J, Roberts, JC, Berg, KM, Cocchi, MN, Donnino, MW. Etiology and therapeutic approach to elevated lactate levels. Mayo Clin Proc. 2013;88(10):1127-1140.CrossRefGoogle Scholar
7. Guyette, F, Suffoletto, B, Castillo, J-L, Quintero, J, Callaway, C, Puyana, J-C. Prehospital serum lactate as a predictor of outcomes in trauma patients: a retrospective observational study. J Trauma. 2011;70(4):782-786.Google ScholarPubMed
8. Moon, JM, Shin, MH, Chun, BJ. The value of initial lactate in patients with carbon monoxide intoxication: in the emergency department. Hum Exp Toxiciology. 2011;30(8):836-843.CrossRefGoogle ScholarPubMed
9. Inoue, S, Saito, T, Tsuji, T, et al. Lactate as a prognostic factor in carbon monoxide poisoning: a case report. Am J Emerg Med. 2008;26(8):966.CrossRefGoogle ScholarPubMed
10. Bernal, W, Donaldson, N, Wyncoll, D, Wendon, J. Blood lactate as an early predictor of outcome in paracetamol-induced acute liver failure: a cohort study. Lancet. 2002;359(9306):558-563.CrossRefGoogle ScholarPubMed
11. Jeng, JC, Jablonski, K, Bridgeman, A, Jordan, MH. Serum lactate, not base deficit, rapidly predicts survival after major burns. Burns. 2002;28(2):161-166.CrossRefGoogle Scholar
12. Mikkelsen, ME, Miltiades, AN, Gaieski, DF, et al. Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock. Crit Care Med. 2009;37(5):1-8.CrossRefGoogle ScholarPubMed
13. Goyal, M, Pines, JM, Drumheller, BC, Gaieski, DF. Point-of-care testing at triage decreases time to lactate level in septic patients. J Emerg Med. 2010;38(5):578-581.CrossRefGoogle ScholarPubMed
14. Seymour, CW, Band, RA, Cooke, CR, et al. Out-of-hospital characteristics and care of patients with severe sepsis: a cohort study. J Crit Care. 2010;25(4):553-562.CrossRefGoogle ScholarPubMed
15. Husain, FA, Martin, MJ, Mullenix, PS, Steele, SR, Elliott, DC. Serum lactate and base deficit as predictors of mortality and morbidity. Am J Surg. 2003;185(5):485-491.CrossRefGoogle ScholarPubMed
16. Gaieski, DF, Drumheller, BC, Goyal, M, Fuchs, BD, Shofer, FS, Zogby, K. Accuracy of handheld point-of-care fingertip lactate measurement in the emergency department. West J Emerg Med. 2013;14(1):58-62.CrossRefGoogle ScholarPubMed
17. Shapiro, NI, Fisher, C, Donnino, M, et al. The feasibility and accuracy of point-of-care lactate measurement in emergency department patients with suspected infection. J Emerg Med. 2010;39(1):89-94.CrossRefGoogle ScholarPubMed
18. Australian Bureau of Statistics. Australian demographic statistics Sep 2015. http://www.abs.gov.au/AUSSTATS/abs@.nsf/mf/3101.0. Published 2015. Accessed March 25, 2016.Google Scholar
19. ACT Health. About Canberra Hospital. http://www.health.act.gov.au/our-services/canberra-hospital-campus/about-canberra-hospital. Published 2016. Accessed March 25, 2016.Google Scholar
20. Bonaventura, JM, Sharpe, K, Knight, E, Fuller, KL, Tanner, RK, Gore, CJ. Reliability and accuracy of six hand-held blood lactate analyzers. J Sports Sci Med. 2015;14(1):203-214.Google Scholar
21. Mikami, A, Ohde, S, Deshpande, G a., Mochizuki, T, Otani, N, Ishimatsu, S. Can we predict arterial lactate from venous lactate in the ED? Am J Emerg Med. 2013;31(7):1118-1120.CrossRefGoogle ScholarPubMed
22. Bland, JM, Altman, DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986;1(8476):307-310.CrossRefGoogle ScholarPubMed
23. Bland, JM, Altman, DG. Statistical methods for assessing agreement between two methods of clinical measurement. Int J Nurs Stud. 2010;47:931-936.CrossRefGoogle Scholar
24. van Beest, PA, Mulder, PJ, Oetomo, SB, van den Broek, B, Kuiper, MA, Spronk, PE. Measurement of lactate in a prehospital setting is related to outcome. Eur J Emerg Med. 2009;16(6):318-322.CrossRefGoogle Scholar