YJCRC-53342; No of Pages 2
Journal of Critical Care xxx (2019) xxx
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Journal of Critical Care
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Venous blood lactate concentrations in patients with shock: Interesting
but not really helpful
A R T IC L E IN F O
Article history:
Received 26 June 2019
Received in revised form 3 July 2019
Accepted 2 August 2019
Available online xxxx
Increased blood lactate concentrations are known to be associated
with adverse outcome in septic patients [1,2]. Besides single lactate
measurements, changes in lactate concentrations over time were re-
ported to be associated with mortality [3]. Beyond risk stratification, lac-
tate concentrations and its dynamics were proposed to constitute a
treatment target. However, this concept in principle, misleadingly la-
beled “lactate clearance” [4], and specifically, its clinical use is still a sub-
ject of debate [5-7]. In a meta-analysis of four trials, a lactate clearance
targeted approach showed favorable outcomes compared to control
[8]. However, in a recent large randomized controlled trial comparing
a resuscitation strategy targeting lactate compared to peripheral perfu-
sion status assessed by capillary refill time did not yield in superior out-
comes [9]. One reason for these distinct outcomes might be due to a lack
of understanding of the specific therapeutic consequences of
hyperlactatemia. In particular, the equation more lactate equals more
intravenous fluids should not be correct in all patients. Recently, in an
extensive study of septic patients, increased lactate concentrations
were related to impaired peripheral oxygen utilization instead of de-
creased oxygen transport [10]. The integration of variables such as
blood pressure, central venous oxygen saturation, base excess, and lac-
tate concentrations could help to develop a more personalized treat-
ment for critically ill patients evidencing increased lactate levels,
depending on the sources and (patho-)physiology of hyperlactatemia
[10,11].
Usually, lactate concentrations are determined from peripheral arte-
rial blood, usually through an arterial line. However, arterial sampling
might not be feasible in all patients and/or settings. Therefore,
Mahmoodpoor and coworkers recently assessed the relationship of ar-
terial with venous blood lactate concentrations [12]. Further, they eval-
uated the predictive value of both lactate concentration at baseline and
the change in lactate levels after 6 h. In their study, including 100 pa-
tients suffering from septic shock after surgery, Mahmoodpoor et al.
found a robust (r = 0.59) correlation of arterial and venous lactate con-
centration at baseline. This correlation persisted at 6 h (r = 0.89). The
https://doi.org/10.1016/j.jcrc.2019.08.007
0883-9441/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: B. Wernly, J. Bakker and C. Jung, Venous blood lactate concentrations in patients with shock: Interesting but not really
helpful, Journal of Critical Care, https://doi.org/10.1016/j.jcrc.2019.08.007
venous lactate concentrations were higher compared to arterial mea-
surements. The predictiveness for mortality of arterial lactate concen-
trations was superior to venous measurements. The authors conclude
that venous and arterial lactate concentrations correlate, and venous
lactate measurements are feasible to initially stratify risk in septic pa-
tients. These findings and conclusions are in accordance with earlier
findings, including critically ill patients admitted to an intensive care
unit [13,14]. Of note, another study evaluating arterial versus venous
blood lactate concentrations in an emergency department setting
found poor agreement, especially if the venous lactate concentration
was abnormal [15].
Therefore, the devil is in the details: In the study of Mahmoodpoor
et al., venous lactate was drawn from a central venous line, which ele-
gantly circumvented the problem with tourniquets and its changes in
local perfusion which might falsely elevate lactate concentrations. How-
ever, the initial idea was to potentially make lactate measurements eas-
ier available in a venous blood gas analysis – this goal is not achieved
using a central venous catheter. Depending on local policies in emer-
gency departments, an arterial line might be available before a central
venous line. Therefore, why should one use central venous lactate con-
centration which lacks predictiveness over the “gold-standard”, periph-
eral arterial lactate? The question of whether peripheral venous lactate
concentration (usually available at presentation) shows similar correla-
tions to arterial lactate concentrations remains unknown. Considering
other reports lacking correlations or reporting only vague associations,
this seems highly questionable [15]. Therefore, based on the available
literature, venous lactate concentration could be used as a binary risk
parameter at best [16]: A peripheral venous blood lactate concentration
below 2.0 mmol/L might indicate a low-risk situation. Peripheral venous
blood lactate concentration above 2.0 mmol/L warrants further
investigations.
Another even faster available method to measure lactate concentra-
tions might be capillary lactate measurement. Capillary lactate mea-
surement can be obtained within a few minutes without the need to
puncture any vessel directly. Several studies, both in animal models
and humans suffering from shock, capillary, and arterial lactate levels
showed acceptable to good correlation [17-19]. Still, there is a bias be-
tween capillary and arterial lactate concentrations, especially if levels
are elevated, and therefore, capillary measurement should – like periph-
eral venous lactate concentration – primarily been seen as a screening
tool for quick initial patient assessment, especially if the arterial punc-
ture is difficult.
Mahmoodpoor et al. split their cohort into three sub-groups based
on arterial lactate concentrations (b3.2 mmol/L or ≥3.2 mmol/L), and
lactate clearance (below or above 20%): Of patients with lactate
2 Venous blood lactate concentrations in patients with shock: Interesting but not really helpful
≥3.2 mmol/L and lactate clearance below 20% evidenced mortality of
100%. This interesting finding is in accordance with other studies
reporting good predictiveness for parameters assessing lactate dynam-
ics in patients with increased initial lactate concentrations [2,20,21].
The exact sources of hyperlactatemia and the precise mechanisms of re-
ducing increased lactate levels to normal range remain interesting
topics of ongoing research [10]. However, a decrease of elevated lactate
concentrations virtually always is a good sign for our patients, a finding
which is not limited to patients suffering from sepsis [22]. On the con-
trary, an increase in lactate levels indicates danger and should prompt
the clinician to question the treatment strategy.
Lactate metabolism is complex and just targeting “lactate clearance”
might not adequately reflect the distinct players contributing to lactate
concentrations [23]. Both increased lactate concentrations at a single
time point and impaired “lactate clearance” might indicate pathological
disturbances and therefore predict risk. Hence, integrating these two
concepts into a tool might help understanding lactate metabolism, in-
crease our capacity to predict risk, and ultimately contribute to improv-
ing outcomes in sepsis.
With regards to lactate measurements, we think that arterial lactate
levels constitute the gold-standard, especially considering the abun-
dance of evidence for a strong link between arterial hyperlactatemia -
especially if persisting over time – and adverse outcome. Peripheral ve-
nous and capillary lactate concentrations could play a role in initial pa-
tient risk stratification, and low venous and/or capillary lactate levels
might indicate lower risk patients. However, it seems questionable
whether arterial lactate concentrations can be replaced by these surro-
gate parameters. Further, as venous and capillary lactate concentrations
can only be seen as a binary variable indicating lower or higher risk, this
information could also be obtained using good old clinical assessment,
including capillary refill time.
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Please cite this article as: B. Wernly, J. Bakker and C. Jung, Venous blood lactate concentrations in patients with shock: Interesting but not really
helpful, Journal of Critical Care, https://doi.org/10.1016/j.jcrc.2019.08.007
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Bernhard Wernly
Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical
University of Salzburg, Salzburg, Austria
Jan Bakker
Department of Intensive Care Adults, Erasmus MC University Medical
Center, Rotterdam, The Netherlands
Christian Jung
Division of Cardiology, Pulmonology and Vascular Medicine, Medical
Faculty, University of Düsseldorf, Düsseldorf, Germany
Corresponding author.
E-mail address: Christian.Jung@med.uni-duesseldorf.de
26 June 2019
Available online xxxx