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Lactate monitoring with subcutaneous microdialysis in patients with shock: a pilot study.

We describe the use of subcutaneous microdialysis for continuous sampling of lactate to monitor the plasma lactate concentration in eight patients with shock. The dialysate lactate concentrations were significantly correlated with the plasma lactate concentrations (r = 0.8229), but the linear regression lines varied between patients. Therefore, we used the individual regression line of each patient for calibration to calculate estimated plasma values from the dialysate concentrations. While the estimated values were linearly correlated to the plasma lactate values (r = 0.912), the 95% confidence interval of the estimated values was +/- 2.8 mmol/L. Thus, subcutaneous microdialysis does not allow accurate estimation of the plasma lactate concentration. In 3 of the 8 patients, there was a significant negative correlation between the dialysate/plasma lactate ratio and the plasma lactate concentration. This suggests that besides plasma lactate, other factors such as subcutaneous adipose tissue metabolism and blood flow, may influence subcutaneous sampling and dialysate lactate concentration as well. While microdialysis can be used for on-line sampling and continuous monitoring of the concentration of extracellular substances, for the purpose of plasma lactate monitoring, sampling probes should be designed that permit intravascular placement.

Adult↗

Microinjection of L-lactate in the preretinal vitreous induces segmental vasodilation in the inner retina of miniature pigs.

PURPOSE: The authors investigated the hypothesis that the retinal vasomotor effect of acute hypoxia is mediated by lactate. METHODS: Retinal vasomotor arteriolar response was measured in the intact eyes of miniature pigs after systemic administration and after local preretinal juxta-arteriolar microinjection of lactate. RESULTS: Injection of L-lactate (physiologically produced lactate) into the systemic circulation decreased the arterial blood pH but did not dilate the retinal arterioles. By contrast, microinjections of L-lactate (0.5 mol/l, pH 2) into the juxta-arteriolar vitreous induced a reversible segmental vasodilation of 32 +/- 4% (standard deviation). This vasodilation did not depend on periarteriolar pH lowering because microinjections of a 0.5 mol/l L-lactate at neutral pH also dilated segmentally the retinal arterioles (37 +/- 5.5%). The effect of lactate was stereospecific because microinjections of the isomer D-lactate (0.5 mol/l, pH 2) did not affect the arteriolar caliber (P = 0.63). Perfusion of the eye with the cyclo-oxygenase inhibitor indomethacin, through cannulization of the sublingual artery, caused a generalized reversible arteriolar vasoconstriction of 51 +/- 9.8% but did not inhibit the segmental vasodilator effect of locally microinjected L-lactate. CONCLUSIONS: It is known that acute hypoxia in the isolated retina causes an increase in lactate production. In the intact eye, there is a retinal vasodilation, which is not inhibited by indomethacin. Hence, it was concluded that retinal, but not blood, lactate is a possible mediator of the acute hypoxia-induced vasodilation.

Animals↗

Lactate catabolism by enzyme-loaded red blood cells.

Two different enzymes that metabolize lactate in the presence of oxygen, either to acetate plus CO2 (lactate 2-mono-oxygenase; Lmox) or to pyruvate plus H2O2 (lactate oxidase; Lox) were encapsulated in human and murine red blood cells (RBCs). Lmox shows a low affinity for lactate (Km 22 mM) and thus works at a low rate at the lactate concentrations found in hyperlactataemia (5-20 mM). Encapsulation of Lox provides a constant catabolic rate under the same range of blood lactate concentrations, but generates H2O2, which is toxic to the enzyme-loaded RBCs. Co-encapsulation of both enzymes at a ratio of 20 units of Lmox/unit of Lox results in significant rates of lactate metabolism over a wide range (1-30 mM) of lactate concentrations with modest methaemoglobin formation (5-8.5%) and normal cellular ATP concentrations (1.1-1.23 mM). In vitro experiments with [1-14C]glucose and [U-14C]glucose have shown that Lmox/Lox-loaded RBCs counteract the production of H2O2 by increasing the amount of glucose metabolized in the pentose phosphate pathway. In vivo attempts to prove the efficacy of these engineered RBCs in removal of blood lactate in mice have failed because of the high aerobic capacity and high lactate metabolism of these animals. However, the results obtained in vitro suggest that the encapsulation of lactate-catabolizing enzymes may be useful in the treatment of hyperlactataemia.

Acetates↗

Influence of different dietary vitamin B6 supply during gravidity and lactation on total vitamin B6 concentration (pyridoxine, pyridoxal and pyridoxamine) in blood and milk.

In a two factorial trial with 80 (5 x 2 x 8) Sprague-Dawley rats weighing 257 g the influence of different dietary vitamin B6 supply on concentration in blood and milk was examined. The two factors were 5 doses of alimentary vitamin B6 supply during pregnancy (0.6, 3, 6, 18, and 180 mg vitamin B6 per kg diet) and 2 doses in lactation (3 and 6 mg vitamin B6 per kg diet). The rats were fed a semisynthetic diet. The daily food intake was 14 g during pregnancy and ad libitum during lactation. At day 7 and 13 of lactation the dams were milked and at day 14 the animals were killed by decapitation. Vitamin B6 concentration of milk at 7th and 13th day of lactation and vitamin B6 concentration of blood at 14th day of lactation were examined. The mean total vitamin B6 concentration in blood was 0.18 microgram/ml and consisted of 94.8% pyridoxal and 5.2% pyridoxamine. An elevation in vitamin B6 supply during pregnancy led to an increase in blood vitamin B6 concentration of 40% and the vitamin B6 treatment during lactation caused an increase of 50%. The mean total vitamin B6 concentration in milk at the 7th day of lactation was 0.35 microgram/ml and consisted of 79.5% pyridoxal, 15.6% pyridoxamine and 4.9% pyridoxine. An elevation in dietary vitamin B6 supply during pregnancy led to an increase in milk vitamin B6 concentration of 79% and vitamin B6 treatment during lactation led to an increase of 38%. The mean total vitamin B6 concentration in milk at the 13th day of lactation was 0.44 microgram/ml and consisted of 79.8% pyridoxal, 13.9% pyridoxamine and 6.3% pyridoxine. Milk vitamin B6 concentration was increased by 53% through the dietary supply during pregnancy and by 32% through the higher lactational supply. The experiments indicate that vitamin B6 concentration in blood and milk is a reflection of dietary supply, whereby in lactation milk concentration is less influenced than blood.

Analysis of Variance↗

Evaluation of lactate as a 1H nuclear magnetic resonance spectroscopy index for noninvasive prediction and early detection of tumor response to radiation therapy in EMT6 tumors.

In a recent study (Int. J. Radiat. Oncol. Biol. Phys. 36, 635-639, 1996), 1H nuclear magnetic resonance (NMR) spectroscopy was used to demonstrate significant decreases in lactate levels after gamma irradiation of radiosensitive RIF-1 tumors in vitro. For comparison, we have examined the effects of gamma radiation on lactate levels in the more radioresistant EMT6 tumor. Single-slice (5-6 mm thick) localized 1H spectra of subcutaneous RIF-1 (untreated) and EMT6 tumors (pretreatment, 24 and 48 h postirradiation with 4, 10 or 20 Gy of gamma radiation) were measured by the selective multiple quantum coherence transfer method (Sel-MQC, approximately 4 min acquisition time). Both pretreatment lactate levels and pretreatment lactate dehydrogenase (LDH) activities were found to be similar in RIF-1 and EMT6 tumors, suggesting that steady-state lactate levels are unlikely to be reliable indices for predicting response to radiation therapy. After 10 Gy gamma irradiation, EMT6 tumors showed a 21% decrease relative to pretreatment lactate levels at 48 h (1.04 +/- 0.22 to 0.82 +/- 0.16; P = 0.06); after 20 Gy a 40% decrease was observed at 48 h (1.34 +/- 0.27 to 0.81 +/- 0.10; P = 0.07). No significant changes in lactate levels were observed in control EMT6 tumors or in tumors treated with 4 Gy of gamma radiation, in contrast to changes detected previously in RIF-1 tumors, which showed a significant decrease in lactate by 48 h for both 2 and 4 Gy. The decreased effect of radiation on lactate levels in EMT6 compared to RIF-1 tumors may be attributed to the higher hypoxic fraction and lower radiosensitivity of EMT6 tumors (Int. J. Radiat. Oncol. Biol. Phys. 10, 695-712, 1984). The decrease in lactate levels did not, however, strictly reflect the extent of the response to therapy for the high dose of 20 Gy. This study together with our earlier study (Int. J. Radiat. Oncol. Biol. Phys. 36, 635-639, 1996) provides evidence to support the hypothesis that changes in steady-state tumor lactate levels may serve as sensitive early indices of tumor response to gamma radiation at doses of the order of 2 to 4 Gy.

Animals↗

[Calcium and phosphorus balance in rural lactating women in Mexico].

OBJECTIVE: To compare the balance of calcium (Ca) and phosphorus (P) between lactation and weaning, and to determine the Ca and P milk production in Mexican rural lactating women. METHODS: Thirty-six women aged 18-36 y, weight 49 +/- 3 kg and height 148 +/- 2 cm, were divided in six groups: four groups of lactation (1st, 3rd, 6th and 12th month) one post-weaning group and one of non pregnant non lactating women. The balance studies were performed collecting duplicate diets, 24 h urine for 3 days, 72 h feces and 24 h milk samples for 2 days. The Ca content was determined by atomic absorption spectrophotometry and P by the molybdate method. RESULTS AND CONCLUSIONS: Ca content in milk was higher in the 3rd month of lactation. The Ca balances were negative in all lactation groups (789 +/- 165 mg/d). Ca urinary excretion was lower in the lactating group (p < 0.05) suggesting a regulatory mechanism to conserve Ca during lactation. No differences were observed in the P content in milk and positive balances of P were observed in the non lactating and the post-weaning groups, whereas they were negative in the lactation groups (115 to 475 mg/d). High fecal Ca and P excretion (approximately 1300 mg/d) was observed, which contributed to the negative condition of the balance during lactation. The production of Ca and P in the milk of these rural women was similar to the one seen in rural and urban groups in Africa, Asia, Europe and the U.S.

Adult↗

The catalytic role of tyrosine 254 in flavocytochrome b2 (L-lactate dehydrogenase from baker's yeast). Comparison between the Y254F and Y254L mutant proteins.

Flavocytochrome b2 catalyses the oxidation of L-lactate to pyruvate in yeast mitochondrial intermembrane space. Its flavoprotein domain is a member of a family of FMN-dependent 2-hydroxy-acid-oxidizing enzymes. Numerous solution studies suggest that the first step of the reaction consists of proton abstraction from lactate C2, leading to a carbanion that subsequently yields electrons to FMN. The crystal structure suggests that the enzyme base is His373, and that Tyr254 may be hydrogen bonded to the substrate hydroxyl. Studies carried out with the Y254F mutant [Dubois, J., Chapman, S.K., Mathews, F.S., Reid, G.A. & Lederer, F. (1990) Biochemistry 29, 6393-6400] showed that Tyr254 does not act as a base but stabilizes the transition state. As the mutation did not induce any change in substrate affinity, the question of the existence of the hydrogen bond in the Michaelis complex remained open. Similar results with glycolate oxidase, mutated at the same position, led to the suggestion that these enzymes actually operate via a hydride transfer mechanism [Macheroux, P., Kieweg, V., Massey, V., Soderlind, E., Stenberg, K. & Lindqvist, Y. (1993) Eur. J. Biochem. 213, 1047-1054]. In the present work, we have re-investigated the matter by analysing the properties of a Y254L mutant flavocytochrome b2, as well as the behaviour of the Y254F enzyme with two substrates other than lactate, and a series of inhibitors. The Y254L protein is less efficient with L-lactate than the wild-type enzyme by a factor of 500, but the substrate affinity is unchanged. In contrast, L-phenyllactate and mandelate, poor substrates (the latter acting more as an inhibitor), exhibit an increased affinity. In addition, the Y254L mutant enzyme is more efficient with phenyllactate than lactate as a substrate. In order to rationalize these observations, we have modelled phenyllactate and mandelate in the active site, using previously described modelling experiments with lactate as a starting point. The results indicate that mandelate cannot bind in an orientation allowing proton abstraction by His373, due to steric interference by the side chains of Ala198 and Leu230. It might possibly adopt a binding mode as proposed previously for lactate, which leads to a hydride transfer and with which the 198 and 230 side chains do not interfere. However, other researchers [Sinclair, R., Reid, G.A. & Chapman, S.K. (1998) Biochem. J. 333, 117-120] showed that A198G, L230A and A198G/L230A mutant enzymes exhibit a strongly improved mandelate dehydrogenase activity. These results indicate that relief of the steric crowding facilitates catalysis by enabling a better mandelate orientation at the active site, suggesting that its productive binding mode is similar to that proposed for lactate in the carbanion mechanism. The modelling studies therefore support the hypothesis of a carbanion mechanism for all substrates. In addition, we present the effect of the two mutations at position 254 on the binding of a number of competitive inhibitors (such as sulfite, D-lactate, propionate) and of inhibitors that are known to bind at the active site both when the flavin is oxidized and when it is in the semiquinone state (propionate, oxalate and L-lactate at high concentrations). Unexpectedly, the results indicate that the integrity of Tyr254 is necessary for the binding of these inhibitors at the semiquinone stage.

Amino Acid Substitution↗

Chemo-enzymatic D-enantiomerization of DL-lactate.

We investigated the total conversion of racemic lactate, L-lactate, and pyruvate into D-lactate, which is very useful as a starting material for the synthesis of chiral compounds and much more valuable than the L-enantiomer by means of coupling of L-specific oxidation of the racemate with L-lactate oxidase and non-enantiospecific reduction of pyruvate to DL-lactate with sodium borohydride. In this one-pot system, L-lactate was enantiospecifically oxidized to an achiral product, pyruvate, which was chemically reduced to DL-lactate leading to a turnover. Consequently, either DL-lactate, L-lactate, or pyruvate was fully converted to the D-enantiomer. We optimized the reaction conditions: DL-lactate was converted to D-lactate in 99% of the theoretical yield and with more than 99% enantiomeric excess. DL-alpha-Hydroxybutyrate and alpha-ketobutyrate were converted also to D-alpha-hydroxybutyrate in the same way, though slowly.

Borohydrides↗

L-lactate protects in vitro acetylcholinesterase (AChE) from inhibition by paraoxon (E 600).

Intoxication with the organophosphorus compound paraoxon (POX), an inhibitor of serine hydrolases, is frequent. Oximes are the only enzyme reactivators clinically available. Recent work has shown that lactate is able to reduce in vitro the POX effects on butyrylcholinesterase (BChE). Most of the acute clinical symptoms, however, are caused by inhibition of acetylcholinesterase (AChE). Effects of lactate on the inhibition of AChE by POX were assessed in vitro in plasma of 12 (six male, six female) healthy human volunteers. The determinations were repeated using different lactate and different POX concentrations. The AChE activity determinations were performed in the following settings: (BL) baseline (untreated plasma); (a) after addition of POX to plasma (pl + POX); (b) after POX and plasma were incubated and then lactate was added (pl + POX/lact); (c) after addition of lactate to plasma (pl + lact); (d) after lactate and plasma were incubated and then POX was added (pl + lact/POX); (e) after lactate and POX were incubated and then added to plasma (lact + POX/pl). In the micro- and millimolar ranges, lactate is able to protect in vitro AChE from inhibition by POX when added to human plasma prior to POX or when incubated with POX prior to addition to plasma. Lactate added to plasma after POX has no protective effect. In a second set of experiments, the effect of lactate on AChE activity was determined. At high millimolar concentrations, lactate itself inhibits AChE non-competitively (mixed inhibition) to an extent comparable to POX (inhibition constant K(I) = 254 mM).

Acetylcholinesterase↗

D-lactate metabolism in starved Octopus ocellatus.

The concentrations of D- and L-lactate, methylglyoxal and pyruvate were measured in tissues of normal and starved Octopus ocellatus. D-Lactate was always more abundant than L-lactate in the tissues. D-Lactate, pyruvate and methylglyoxal were present in 320, 94 and 43 times higher concentrations in tentacle of O. ocellatus of control group than those in normal rat skeletal muscle. The D-lactate concentration in the tentacle of O. ocellatus was 17-fold higher than that in Octopus vulgars. The activities of enzymes involved with D-lactate metabolism such as pyruvate kinase, octopine dehydrogenase, glyoxalase I and II and lactate dehydrogenase were measured in those tissues. The activities of glyoxalase I and II, and D-lactate dehydrogenase were increased in mantle and tentacle of starved octopus, while the levels of D-lactate and related metabolites were lowered in these tissues. The experimental results presented in this report and up to the present indicate that D-lactate is actively used for energy production in the tentacle and mantle of the starved animals. In octopus, especially starved octopus D-lactate was actively produced from methylglyoxal, which is formed via aminoacetone from threonine and glycine.

Animals↗

Monitoring arterio-venous differences of glucose and lactate in the anesthetized rat with or without brain damage with ultrafiltration and biosensor technology.

Continuous monitoring of arterio-venous glucose and lactate differences may serve as a diagnostic tool to assess normal brain function and brain pathology. We describe a method and some results obtained with arterio-venous measurements of glucose and lactate in the blood of the halothane-anesthetized rat and after brain injury. The method is based on low flow rate ultrafiltration for continuous collection of blood filtrate combined with flow injection analysis and biosensors for the detection of glucose and lactate. We measured the glucose and lactate concentration every minute in the jugular vein and the aorta at control conditions and during and after inflation of an embolectomy-balloon for 2 min. Net cerebral lactate efflux and glucose uptake was seen under control conditions and at low blood lactate levels. During brain injury both lactate release and glucose uptake were reduced and there was a net lactate influx at high arterial lactate levels. These results indicate that the flux of lactate in and out of the brain is not only dependent on the lactate concentration in the brain, but on blood levels as well, possibly because of bi-directional flux through the monocarboxylate transporter type 1.

Anesthetics↗

Lactate utilization by brain cells and its role in CNS development.

We studied the role played by lactate as an important substrate for the brain during the perinatal period. Under these circumstances, lactate is the main substrate for brain development and is used as a source of energy and carbon skeletons. In fact, lactate is used actively by brain cells in culture. Neurons, astrocytes, and oligodendrocytes use lactate as a preferential substrate for both energy purposes and as precursor of lipids. Astrocytes use lactate and other metabolic substrates for the synthesis of oleic acid, a new neurotrophic factor. Oligodendrocytes mainly use lactate as precursor of lipids, presumably those used to synthesize myelin. Neurons use lactate as a source of energy and as precursor of lipids. During the perinatal period, neurons may use blood lactate directly to meet the need for the energy and carbon skeletons required for proliferation and differentiation. During adult life, however, the lactate used by neurons may come from astrocytes, in which lactate is the final product of glycogen breakdown. It may be concluded that lactate plays an important role in brain development.

Animals↗

The value of capillary whole blood lactate for blood transfusion requirements in anaemia of prematurity.

OBJECTIVE: To evaluate the usefulness of blood lactate as an indication for blood transfusion in anaemia of prematurity by means of a study protocol which considers the site of blood sampling and the repeatability of lactate measurements. DESIGN: Prospective clinical study. SETTING: Multidisciplinary, neonatalpaediatric intensive care unit of a non-university, teaching children's hospital. PATIENTS AND METHODS: Comparison of pre- and 48-h post-transfusion capillary whole blood lactate in 18 anaemic premature babies. In 30 neonates the agreement between capillary and arterial lactate was analysed by using the Bland Altman plot. In 30 stable premature infants four capillary lactate measurements were carried out within 24 h and analysed with regard to variability (coefficient of variation (CV); association between SD and mean) and to establish normal values. RESULTS: In the transfused infants, haematocrit increased from 23 (SD 3)% to 37 (SD 3)%. Mean lactate decreased from 2.5 (SD 1.0) to 1.7 (SD 0.5) mmol/l (p = 0.003). Pretransfusion lactate did not correlate with pre-transfusion haematocrit, heart rate, respiratory rate, number of apnoeas/bradycardias and weight gain (multiple regression). The mean difference between capillary and arterial lactate was 0.17 (SD 0.24) mmol/l and the 95 % confidence interval (CI) was -0.31 to 0.65 mmol/l. The CV of repetitive measurements was 19.8 (SD 9.8)% and SD correlated positively with mean lactate values (p = 0.001); the 95 % CI (normal range for premature infants) was 1.56-1.90 mmol/l. CONCLUSIONS: Capillary whole blood lactate measurements in newborn babies agree excellently with arterial values. Lactate measurements add little information to the decision whether to transfuse or not, considering the variability of this parameter in stable premature infants and the lack of correlation with other possible clinical indicators of compromised oxygen delivery.

Anemia, Neonatal↗

The role of skeletal muscle and liver on lactate metabolism during hypoxia in rats.

PURPOSE: This study was planned to investigate whether the skeletal muscle and liver produce or consume lactate under hypoxic conditions. METHODS: Wister rats were anesthetized and mechanically ventilated. Microdialysis probes were inserted into the rat skeletal muscle and liver, and arterial cannulation was performed. Hypoxia was induced for 30 min by the inhalation of 10% oxygen in nitrogen. Interstitial lactate concentrations in the skeletal muscle and liver were measured using an in vivo microdialysis method before, during, and after hypoxic hypoxia. The blood lactate concentration, mean arterial blood pressure, and blood gas were also measured. RESULTS: Before hypoxia, there was no significant difference among the blood lactate concentration and interstitial lactate concentrations of the skeletal muscle and liver. During hypoxia, arterial oxygen tension decreased to 34.2 +/- 1.3 mmHg, and the lactate concentrations in these tissues increased significantly in comparison to the control values. However, the lactate concentrations in the skeletal muscle and liver interstitium were significantly lower than that in the blood, with the peak lactate concentration in the skeletal muscle interstitium being only one-third of that in the blood. After correction of hypoxia, the blood lactate concentration decreased to levels comparable to the skeletal muscle and liver interstitial lactate concentrations. CONCLUSION: It is suggested that the skeletal muscle as well as the liver may consume lactate under hypoxic hypoxia.

Journal Article↗

Serum lactate and base deficit as predictors of mortality after ruptured abdominal aortic aneurysm repair.

OBJECTIVE: Whole body hypoperfusion and lower torso ischaemia-reperfusion contribute to post-operative organ dysfunction in patients undergoing repair of ruptured abdominal aortic aneurysm (AAA). Serum lactate and base deficit are markers of tissue ischaemia and are used to assess the adequacy of resuscitation. This study examines the prognostic value of immediate post-operative levels of serum lactate and base deficit in ruptured AAA. METHODS: Thirty patients (24 men and 6 women of median age 74, range 51-85, years) who survived to at least 12h after ruptured AAA repair were studied retrospectively. The relationship between immediate post-operative lactate, base deficit and mortality was determined. RESULTS: Fifteen patients (50%) died, all from organ failure. An elevated lactate (>2.1 mmol/l) and base deficit (<-2 mmol/l) were present in 20 (67%) and 27 (90%) patients, respectively. Lactate (p<0.001) and base deficit (p=0.003) were significantly higher in non-survivors compared with survivors. Lactate (p=0.021) and base deficit levels (p=0.028) were independently significant for predicting mortality and a significant interaction existed between lactate and base deficit levels for predicting mortality (p=0.027). The sensitivity and specificity of lactate > or =4.0 mmol/l was 13 of 15 (87%) and 12 of 15 (80%), respectively, and base deficit < or =-7 mmol/l was 12 of 15 (80%) and 12 of 15 (80%), respectively. The likelihood ratios for a positive result with the defined cut-off values for lactate and base deficit were 4.3 and 4.0, respectively. Lactate > or =4.0 mmol/l and base deficit or =-7 mmol/l were associated with a 4% probability of death. CONCLUSION: These data demonstrate that an immediate post-operative serum lactate > or =4.0 mmol/l and base deficit < or =-7 mmol/l are good predictors of outcome after ruptured AAA repair. The prognostic value of these simple and inexpensive tests require corroboration in a larger prospective study.

Acid-Base Imbalance↗

Predictive value of fetal scalp blood lactate concentration and pH as markers of neurologic disability.

OBJECTIVES: We aimed to analyze the predictive value of the fetal scalp blood lactate concentration and pH, especially in regard to outcome variables that are strong predictors of impaired long-term outcome. An additional aim was to establish cutoff lactate levels in fetal scalp blood. STUDY DESIGN: We conducted a retrospective study of all patients who had fetal scalp blood sampling performed because of an ominous fetal heart rate pattern at Huddinge University Hospital from October 1993 to October 1998. Fetal scalp blood sampling was performed in 1709 patients. The pH and the lactate concentration were determined in fetal scalp blood of 1221 and 814 of these patients, respectively. Outcome variables included pH <7.0 in umbilical artery blood; base deficit >16.0 mmol/L in umbilical artery blood; Apgar scores <7 at 1 minute, <7 at 5 minutes, and <4 at 5 minutes; and hypoxic-ischemic encephalopathy. RESULTS: Sensitivity and specificity were generally higher in the lactate group than in the pH group, particularly in relation to an Apgar score <4 at 5 minutes and moderate to severe hypoxic-ischemic encephalopathy. In 326 patients the scalp blood lactate concentration and pH value had been obtained at the same time, thus allowing a comparison between these methods. The areas under the receiver operating characteristic curves were significantly higher for the lactate concentration than for the pH value with 2 outcome variables: Apgar score <4 at 5 minutes (P =.033) and moderate to severe hypoxic-ischemic encephalopathy (P =.015). CONCLUSIONS: Our findings suggest that determination of the lactate concentration in fetal scalp blood is a more sensitive diagnostic tool than is determination of the pH value for predicting either an Apgar score <4 at 5 minutes or moderate to severe hypoxic-ischemic encephalopathy. In previous studies we also showed lactate measurements to be more often successful than pH analysis. Therefore we consider the measurement of lactate in fetal scalp blood to be an attractive alternative to pH analysis, and determination of the lactate concentration in fetal scalp blood seems to be a useful tool for monitoring the condition of the fetus. A suitable cutoff limit for fetal scalp blood lactate concentration as an indicator of fetal asphyxia could be 4.8 mmol/L.

Apgar Score↗

Prolonged lactate clearance is associated with increased mortality in the surgical intensive care unit.

BACKGROUND: Failure of arterial serum lactate to achieve normal levels has been associated with an increased mortality among medical and trauma patients. At our institution the ability of the patient to normalize arterial serum lactate has been utilized as an end point of resuscitation. In this study, we examine the correlation between length of time to lactate normalization and mortality. METHODS: The charts of 95 consecutive surgical intensive care unit (SICU) patients requiring hemodynamic monitoring or therapy were reviewed retrospectively. Hemodynamic, demographic, and laboratory data were recorded. Patients were stratified by lactate normalization time, and a subgroup analysis of survivors and nonsurvivors was performed by univariate and multivariate analysis. RESULTS: Patients not achieving a normal lactate level sustained a 100% hospital mortality rate. Those clearing between 48 and 96 hours sustained a 42.5% mortality rate. Patients normalizing in 24 to 48 hours had a 13.3% mortality rate, and those clearing in less than 24 hours had a mortality rate of 3.9%. Subgroup analysis by survival revealed differences in time to lactate clearance, initial blood pressure, and initial lactate on univariate analysis. On multivariate analysis only time of lactate clearance was found to differ. CONCLUSIONS: Prolongation of lactate clearance is associated with increasing mortality. Failure of a patient to normalize lactate is associated with 100% mortality. Measurement of arterial serum lactate is a simple and effective predictor of outcome and end point of therapy.

APACHE↗

Hyperpolarization of the cell membrane of mouse hepatocytes by lactate, pyruvate, and fructose is due to Ca2+-dependent activation of K+ channels and of the Na+/K+-ATPase.

Using superfused mouse liver slices combined with a conventional microelectrode technique, we investigated: (1) the ionic mechanisms involved in the hyperpolarization of the hepatocyte membrane induced by lactate and other gluconeogenic substrates; (2) whether these mechanisms are similar to those underlying the hyperpolarization induced by cell swelling in hypo-osmotic medium; and (3) whether the hyperpolarizing effect of lactate on the hepatocyte membrane is related to gluconeogenesis. Lactate (5 mmol/l) hyperpolarized the hepatocyte membrane after an exposure of 10-20 min, and the hyperpolarization was still present after 70 min. The hyperpolarization induced by lactate, pyruvate (5 mmol/l) and fructose (10 mmol/l), and by exposure to hypo-osmotic medium (250 mosmol/l) was antagonized by ouabain, tetraethylammonium (TEA), and cetiedil (lactate; hypo-osmotic medium). Hyperpolarization induced by lactate was eliminated or attenuated by agents impairing activation of Ca2+-dependent K+ channels, by amiloride, and by a blockade of non-selective cation channels with flufenamic acid and gadolinium. Thapsigargin, increasing cytosolic Ca2+, mimicked lactate's hyperpolarizing effect. Lactate's effect was dependent on extracellular Ca2+. Finally, lactate's hyperpolarizing effect was reduced by inhibiting gluconeogenesis. These findings suggest that metabolism of lactate hyperpolarizes hepatocytes by mechanisms analogous to those underlying the hyperpolarization induced by cell swelling in hypo-osmotic medium. Gluconeogenesis from lactate may cause cell swelling, subsequent activation of Ca2+-dependent K+ channels and of the Na+/K+-ATPase, and thus hyperpolarize the hepatocyte membrane.

Amiloride↗