Page 39 - 2020 JSOM Winter

1 2

IMAGE 1 Malaria parasites are
identifiable by their blue stain inside the
cells. This picture shows an excellent
example of a properly prepared thick/thin
smear—the cells are side by side without
overlapping.
3 4
IMAGES 2 AND 4 from cdc.gov.

IMAGE 3 from pathpedia.com.

APPENDIX E: LACTATE

Lactate can be measured with the CG4 i-STAT cartridge. This ◆ Trend lactic acid levels at a frequency of every 4–6
specific cartridge must be stored in a temperature-controlled hours. Lactate improvement will lag behind improve-
environment. Lactate can also be measured using a lactate- ment in vital signs, mental status, and urine output.
specific device but many are not approved for medical man- ◆ If patient is underresuscitated, or resistant to resuscita-
agement of critical patients. 1 tion, vital signs and organ dysfunction assessments will
continue to be abnormal, with no appreciable response,
Adding lactate to other resuscitation endpoints is beneficial, and lactate will remain elevated.
however patients should be monitored using a “whole patient” ◆ If other markers of resuscitation are improving and the
approach. He or she could be doing well clinically with an ad- patient is clinically improving, but lactate is not de-
equate blood pressure and capillary refill, good urine output, creasing or is increasing, it could be an indication of
and down-titrating vasopressors, but continues to have a per- tissue reperfusion (flushing out vascular beds that have
sistently elevated lactate level. There are many reasons for this, not been perfused due to shock). Keep trending lactate,
some of which do not require a clinical response, only further and if it remains elevated or is increasing, this could
monitoring. Lactate levels have a direct impact on a patient’s be an indication of a source of infection that has not
pH (acidosis), however the main adverse effects of acidosis are been adequately addressed and may require a change in
a) decreased cardiac output and vascular “tone,” which will anti biotic regimen, and/or surgical intervention. Obtain
be seen as persistent hypotension and b) impaired coagulation, tele medicine consult.
which will be seen as bleeding despite adequate blood product
resuscitation and source control. In general, these effects do Reference
not occur at a pH above 7.2 (which does not correlate directly 1. Bonaventura JM, Sharpe K, Knight E, et al. Reliability and accu-
to a specific lactate level). racy of six hand-held blood lactate analysers. J Sports Sci Med.
2015;14(1):203–214.
If lactic acid levels are available, they should be integrated into
patient monitoring as follows:

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