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The Use and Clinical Importance of a Substrate-Specific Electrode for Rapid Determination of Blood Lactate Concentrations
Javier Aduen, MD;
Wendy K. Bernstein, MD;
Terrance Khastgir, MD;
JoAnn Miller, RN;
Roger Kerzner;
Asha Bhatiani;
Jack Lustgarten, PhD;
Avtar S. Bassin, MD;
Lindsay Davison;
Bart Chernow, MD
JAMA. 1994;272(21):1678-1685.
Abstract
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Objective.
—To determine the validity and clinical importance of a newly developed amperometric, enzymatic, substrate-specific electrode for the rapid measurement of circulating lactate concentrations.
Design.
—A prospective multiexperiment study.
Setting.
—The critical care medicine research laboratory, intensive care unit (ICU), emergency department (ED), and general wards of a university-affiliated hospital.
Patients.
—A total of 1218 patients and control subjects were studied on one or more occasions.
Interventions.
—Blood lactate concentrations, descriptive data, physiological parameters, and outcome results were determined in various patient populations.
Main Outcome Measures and Results.
—Experiment 1: Lactate determinations performed with the new substrate-specific electrode were compared with two laboratory reference methods. Blood samples from 80 ICU patients and 165 ED patients formed the basis of this first experiment. There was excellent agreement between the test instrument and the two reference methods as reflected by bias (with reference method 1, 0.19 mmol/L; reference method 2, 0.09 mmol/L), precision (with reference method 1, ±0.47 mmol/L; reference method 2, ±0.34 mmol/L), and correlation data (with reference method 1, r=.92; reference method 2, r=.98). Experiment 2: The new test microchemistry instrument was used to analyze blood samples from 927 patients. The mean (SE) blood lactate concentrations in the various patient populations were 1.26 (0.04) mmol/L for control subjects (n=85), 1.52 (0.03) mmol/L for general ward patients (n=489; P<.001 vs normal subjects), 2.34 (0.15) mmol/L for ICU patients (n=180; P<.001 vs normal subjects and general ward patients), and 2.44 (0.15) mmol/L for ED patients (n=173; P<.001 vs normal subjects and general ward patients). None of the normal subjects and only one (0.2%) of 489 nonhypotensive general ward patients had a blood lactate value greater than 4 mmol/L. Circulating lactate concentrations greater than 4 mmol/L were 98.2% specific in predicting the need for hospital admission in patients presenting to the ED. Furthermore, lactate concentrations greater than 4 mmol/L were 96% specific in predicting mortality in hospitalized nonhypotensive patients. Experiment 3: Blood samples from 46 hypotensive ICU and ED patients and from 353 nonhypotensive ICU and ED patients (the latter samples were derived from experiment 2) were analyzed. A statistically significant difference was noted between the mean (SE) lactate concentration in hypotensive patients in the ICU and ED (4.75 [0.75] mmol/L) when compared with nonhypotensive ICU and ED patients (2.28 [0.10] mmol/L; P<.001). Furthermore, blood lactate values greater than 4 mmol/L were 87.5% specific in predicting mortality in hypotensive patients.
Conclusions.
—Lactate determinations performed using the new test instrument are precise and accurate. Blood lactate concentrations greater than 4 mmol/L are unusual in normal and noncritically ill hospitalized patients and warrant concern. In hospitalized (non-ICU) nonhypotensive subjects, as well as in critically ill patients, a blood lactate concentration greater than 4 mmol/L may portend a poor prognosis.
(JAMA. 1994;272:1678-1685)
Author Affiliations
From the Departments of Medicine (Drs Aduen, Bernstein, Khastgir, Bassin, and Chernow, Mss Miller, Bhatiani, and Davison, and Mr Kerzner) and Pathology (Dr Lustgarten), Sinai Hospital of Baltimore, and Departments of Medicine (Drs Aduen and Chernow) and Anesthesia and Critical Care (Drs Bernstein and Chernow), The Johns Hopkins University School of Medicine, Baltimore, Md. Dr Khastgir is now with the Division of Cardiology, University of Oklahoma Health Science Center, Oklahoma City. Dr Bassin is now with the Division of Pulmonary and Critical Care Medicine, Winthrop University Hospital, Mineola, NY. Dr Chernow has received occasional honoraria from NOVA Biomedical in support of lectures he has given.
Footnotes
Reprint requests to Department of Medicine, Sinai Hospital of Baltimore, 2401 Belvedere Ave, Baltimore, MD 21215-5271 (Dr Chernow).
Concepts in Emergency and Critical Care section editor: Roger C. Bone, MD, Consulting Editor, JAMA.
Advisory Panel: Bart Chernow, MD, Baltimore, Md; David Dantzker, MD, New Hyde Park, NY; Jerrold Leiken, MD, Chicago, Ill; Joseph E. Parrillo, MD, Chicago, Ill; William J. Sibbald, MD, London, Ontario; and Jean-Louis Vincent, MD, PhD, Brussels, Belgium.
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