Академический Документы
Профессиональный Документы
Культура Документы
1. BLOOD LACTATE
2. MIXED VENOUS OXYGEN
SATURATION
3. TISSUE Pco2 MONITORING
(TONOMETERY)
4. NEAR INFRARED SPECTROSCOPY
(OPTICAL MONITORING METHODS)
BLOOD LACTATE
HISTORY
LACTATE METABOLISM
MEASUREMENT OF LACTATE
HYRELACTATEIMA AND CAUSES
LACTATE IN SEPSIS
HISTORY
1922: Otto Meyerhoff and Archibald
V. Hill win Nobel prize for energy
capabilities of carbohydrate
metabolism
Accepted that lactate production
causes acidosis
HISTORY
Late 1950s: Huckabee established:
Hypoperfusion Lactic Acidosis
REGULATION OF PATHWAY
REGULATION OF PATHWAY
Thiamine (cofactor of PDH) Deficiency- lactate
production
Oral biguanides/ Hypoglycemic- inhibit renal and
hepatic gluconeogenesis which supplies NAD+ for
lactate to pyruvate conversion.
Measurement of lactate
1.Spectrophotometric analysers measure lactate in
deproteinized blood by using LDH to oxidize lactate
in the presence of nicotinamide dinucleotide (NAD+)
to pyruvate. Light at 340 nm is used to measure the
dihydro nicotinamide adenine dinucleotide (NADH)
formed.
2. Lactate measurements obtained from blood gas
analysers use a modified amperometric cell. The cell
contains the enzyme lactate oxidase, which produces
hydrogen peroxide from lactate. The hydrogen
peroxide is oxidized at a platinum anode producing a
current proportional to the lactate concentration .
Measurement of lactate
The amperometric cell reads 13% higher than the
spectrophotometric analyser; correcting for
haematocrit reduces this difference.
In vitro red cell glycolysis leads to false elevation
of whole blood lactate.
Specimens that are not immediately analysed
should be stabilized. This can be achieved by
cooling, protein precipitation or by addition of
glycolytic inhibitors.
Measurement of lactate
3. Lactate Pro 2- A blood lactate test meter speedily
measures lactate with only a small sample of
blood.Only a 0.3l blood sample is required.
Speedy measurements in 15 sec.
TYPES OF LACTATE
Lactate exists in two isomers:
L-lactate and D-lactate.
Current lactate measurements only include Llactate (the primary isomer produced in humans)
D-lactate is produced by bacteria in the human
colon when they are exposed to large amounts of
unabsorbed carbohydrates.
In the setting of alteration in the intestinal flora and
a high carbohydrate load (such as in short bowel
syndrome) there will be an excess production of Dlactate, which can cross into the bloodstream and
potentially cause neurologic symptoms.
Definitions
Normal lactate: 0.3-1.3 mmol/L
Unstressed: 0.5-1 mmol/L
Stressed: < 2 mmol/L
SOURCE OF LACTATE IN
SEPSIS
Tissue hypoxia
Mitochondrial dysfunction
Pyruvate dehydrogenase inactivity
DO2-VO2 mismatch
Techniques of measurement
1. Intermittent blood sampling Co-oximetry
2. Indwelling Fiber optic catheter oxygen saturation
of venous blood can be measure continuously.
. Issues- Tip position may influence signal quality (SQI)
and readings if the tip is positioned against a vessel
wall.
. Fluids infused through the distal lumen may also
influence SQI and readings (e.g., lipids such as TPN or
propofol, green or blue dyes, and crystalloid infusions
at high flow rates).
. Catheter kinking may also result in a high SQI.
(Both the large distal lumen and the sending/ receiving
optics reside at the tip of the catheter)
LOW SVO2
A low SvO2 is most suggestive of increased
extraction (VO2)
Decrease oxygen delivery (DO2)
HIGH SVO2
SvO2 may be FALSELY ELEVATED :
if the tip of the pulmonary artery catheter is
wedged or distally placed or
HIGH SVO2
Rarely, a high SvO2 reading may
indicate failure of the cells to
extract.This could occur in end
stage multi organ failure or with cell
toxins such as cyanide
Shunting of oxygenated blood past
tissue
Recent focus has shifted away from this approach due to the
introduction of error by estimating intra mucosal bicarbonate
from serum bicarbonate.
SUBLINGUAL TONOMETERY
New technology for intermittent measurement of
partial pressure of sublingual carbon dioxide
(PslCO2).
It is used as a surrogate markers of
gastrointestinal perfusion.
Probe is placed under the tongue in contact with
sub mucosa and measurement is available in 24mins.
Capno-probe consist of
disposable sensor covered with
a membrane permeable to
carbon dioxide.
The sensor contains a
fluorescent dye that emits a
light in direct proportion to the
amount of carbon dioxide
present.
Fibro-optic technology is used to
detect the changes in the
fluorescence and these light
signals are converted into
numeric values.
NEAR INFRARED
SPECTROSCOPY