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December 7, 1994, Vol 272, No. 21 >
ARTICLE | December 7, 1994

The Use and Clinical Importance of a Substrate-Specific Electrode for Rapid Determination of Blood Lactate Concentrations FREE

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
[+] Author Affiliations

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.


JAMA. 1994;272(21):1678-1685. doi:10.1001/jama.1994.03520210062033
Text Size: A A A
Published online
Article
References

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)

REFERENCES

1 +
Gaglio G.  Die Milchsaure des Blutes und ihre Ursprungsstatten. Arch Anat Physiol Abt . 1886;; 10:400-414.
2 +
Barker SB, Summerson WH.  The colorimetric determination of lactic acid in biological material. J Biol Chem . 1941;;138:535-545.
3 +
Broder G, Weil MH.  Excess lactate: an index of reversibility of shock in human patients. Science . 1964;;143:1457-1459.
4 +
Racine P, Klenk HO, Kochsiek K.  Rapid lactate determination with an electrochemical enzymatic sensor: clinical usability and comparative measurements. Z Klin Chem Klin Biochem . 1975;;13:533-539.
5 +
Ronco JJ, Fenwick JC, Wiggs BR, et al.  Oxygen consumption is independent of increases in oxygen delivery by dobutamine in septic patients who have normal or increased plasma lactate. Am Rev Respir Dis . 1993;;147:25-31.
6 +
Bishop MH, Shoemaker WC, Appel PL, et al.  Relationship between supranormal circulatory values, time delays, and outcome in severely traumatized patients. Crit Care Med . 1993;;21:56-63.
7 +
Shoemaker WC, Appel PL, Kram HB.  Hemodynamic and oxygen transport responses in survivors and nonsurvivors of high-risk surgery. Crit Care Med . 1993;;21:977-990.
8 +
Fleming A, Bishop M, Shoemaker W, et al.  Prospective trial of supranormal values as goals of resuscitation in severe trauma. Arch Surg . 1992;; 127:1175-1181.
9 +
Ronco JJ, Fenwick JC, Tweeddale MG, et al.  Identification of the critical oxygen delivery for anaerobic metabolism in critically ill septic and nonseptic humans. JAMA . 1993;;270:1724-1730.
10 +
Abramson D, Scalea TM, Hitchcock R, et al.  Lactate clearance and survival following injury. J Trauma . 1993;;35:584-589.
11 +
Chernow B.  The bedside laboratory. Chest . 1990;; 97:183S-184S.
12 +
Salem M, Chernow B, Burke R, Stacey J, Slogoff M, Sood S.  Bedside diagnostic blood testing: its accuracy, rapidity, and utility in blood conservation. JAMA . 1991;;266:382-389.
13 +
Chernow B, Salem M, Stacey J.  Blood conservation: a critical care imperative. Crit Care Med . 1991;;19:313-314.
14 +
Chernow B.  Blood conservation in critical care: the evidence accumulates. Crit Care Med . 1993;;21: 481-482.
15 +
Schoen I, Graham GA, Custer E, Bandi Z, Georgewill D.  Clinically useful limits (CUL) criteria as a basis for quality control including minimal and optimal goals for quality control. Am J Clin Pathol . 1989;;91:172-181.
16 +
Bernstein WK, Aduen J, Bhatiani A, et al.  Simultaneous arterial and venous lactate determinations in critically ill patients. Crit Care Med . 1994;; 22:A227. Abstract.
17 +
Bland JM, Altman DG.  Statistical methods for assessing agreement between two methods of clinical measurement. Lancet . 1986;;1:307-310.
18 +
Greenburg AG.  Is survival related to failure in oxygen delivery? Crit Care Med . 1993;;21:954.
19 +
Silverman HJ.  Lack of a relationship between induced changes in oxygen consumption and changes in lactate levels. Chest . 1991;;100:1012-1015.
20 +
Kruse JA, Haupt MT, Puri VK, Carlson RW.  Lactate levels as predictors of the relationship between oxygen delivery and consumption in ARDS. Chest . 1990;;98:959-962.
21 +
Nimmo GR, Mackenzie SJ, Walker SW, et al.  The relationship of blood lactate concentrations, oxygen delivery, and oxygen consumption in septic shock and the adult respiratory distress syndrome. Anaesthesia . 1992;;47:1023-1028.
22 +
Toffaletti J, Hammes ME, Gray R, et al.  Lactate measured in diluted and undiluted whole blood and plasma: comparison of methods and effect of hematocrit. Clin Chem . 1992;;38:2430-2434.
23 +
Prentice A, Vagdama P, Dunlop W.  Changes in plasma and whole blood lactate in response to arterial occlusion. Intensive Care Med . 1990;;16:28-32.
24 +
Kruse JA, Carlson RW.  Lactate measurement: plasma or blood? Intensive Care Med . 1990;;16:1-2.
25 +
Huckabee WE.  Abnormal resting blood lactate. Am J Med . 1961;;30:833-839.
26 +
Rashkin MC, Bosken C, Baughman RP.  Oxygen delivery in critically ill patients: relationship to blood lactate and survival. Chest . 1985;;87:580-584.
27 +
Blair E, Cowley RA, Tait MK.  Refractory septic shock in man: role of lactate and pyruvate metabolism and acid-base balance in prognosis. Am Surg . 1965;;31:537-540.
28 +
Weil MH, Ruiz CE, Michaels S, Rackow EC.  Acid-base determinants of survival after cardiopulmonary resuscitation. Crit Care Med . 1985;;13: 888-892.
29 +
Henning RJ, Weil MH, Weiner F.  Blood lactate as a prognostic indicator of survival in patients with acute myocardial infarction. Circ Shock . 1982;;9:307-315.
30 +
Perret C, Enrico JF.  Lactate in acute circulatory failure.  In: Bossart H, Perret C, eds. Lactate in Acute Conditions . New York, NY: S Karger; 1979;:69-82.
31 +
Weil MH, Afifi AA.  Experimental and clinical studies on lactate and pyruvate as indicators of the severity of acute circulatory failure. Circulation . 1970;;41:989-1001.
32 +
Bakker J, Coffernils M, Leon M, et al.  Blood lactate levels are superior to oxygen-derived variables in predicting outcome in human septic shock. Chest . 1991;;99:956-962.
33 +
Parker MM, Shelhamer JH, Natanson C, et al.  Serial cardiovascular variables in survivors and nonsurvivors of human septic shock: heart rate as an early predictor of prognosis. Crit Care Med . 1987;; 15:923-929.
34 +
Tuchschmidt J, Fried J, Swinney R, Sharma OMP.  Early hemodynamic correlates of survival in patients with septic shock. Crit Care Med . 1989;; 17:719-723.
35 +
Siegel JH, Rivkind AI, Dalal S, Goodarzi S.  Early physiologic predictors of injury severity and death in blunt multiple trauma. Arch Surg . 1990;; 125:498-508.
36 +
Vincent JL, Dufaye P, Berre J, et al.  Serial lactate determinations during circulatory shock. Crit Care Med . 1983;;11:449-451.
37 +
Peretz DI, McGragor M, Dossetor JB.  Lactic acidosis: a clinically significant aspect of shock. Can Med Assoc J . 1964;;90:673-675.
38 +
Cowan BN, Burns HJG, Boyle P, Ledingham MCA.  The relative prognostic value of lactate and hemodynamic measurements in early shock. Anaesthesia . 1984;;39:759-755.
39 +
Schuster HP.  Prognostic value of blood lactate in critically ill patients. Resuscitation . 1984;;11:141-146.
40 +
Falk JL, Rackow EC, Leavy J, et al.  Delayed lactate clearance in patients surviving circulatory shock. Acute Care . 1985;;11: 212-215.
41 +
Cady L, Weil MH, Afifi A, et al.  Quantification of severity of critical illness with special reference to blood lactate. Crit Care Med . 1973;;1:75-80.
42 +
Mavric Z, Zaputovic L, Zagar D, et al.  Usefulness of blood lactate as a predictor of shock development in acute myocardial infarction. Am J Cardiol . 1991;;67:565-568.
43 +
Groeneveld ABJ, Kester ADM, NautaJJP, Thijs LG.  Relation of arterial blood lactate to oxygen delivery and hemodynamic variables in human shock states. Circ Shock . 1987;;22:35-53.
44 +
Dunham CM, Siegel JH, Weireter L, et al.  Oxygen debt and metabolic acidemia as quantitative predictors of mortality and the severity of the ischemic insult in hemorrhagic shock. Crit Care Med . 1991;;19:231-243.
45 +
Gutierrez G, Bismar H, Dantzker DR, Silva N.  Comparison of gastric intramucosal pH with measures of oxygen transport and consumption in critically ill patients. Crit Care Med . 1992;;20:451-457.
46 +
Roumen RMH, Redl H, Schlag G, et al.  Scoring systems and blood lactate concentrations in relation to the development of adult respiratory distress syndrome and multiple organ failure in severely traumatized patients. J Trauma . 1993;;35: 349-355.
47 +
Stacpoole PW.  Lactic acidosis. Endocrinol Metab Clin North Am . 1993;;22:221-245.
48 +
Hotchkiss RS, Karl IE.  Reevaluation of the role of cellular hypoxia and bioenergetic failure in sepsis. JAMA . 1992;;267:1503-1510.
49 +
Schimassek H.  Lactate metabolism in the isolated perfused rat liver. Ann N Y Acad Sci . 1965;; 119:1013-1028.
50 +
Almenoff PL, Leavy J, Weil MH, et al.  Prolongation of the half-life of lactate after maximal exercise in patients with hepatic dysfunction. Crit Care Med . 1989;;17:870-873.
51 +
Landow L.  Splanchnic lactate production in cardiac surgery patients. Crit Care Med . 1993;;21( (suppl) ): S84-S91.
52 +
Leavy JA, Weil MH, Rackow EC.  'Lactate washout' following circulatory arrest. JAMA . 1988;;260: 662-664.
53 +
Meerbaum S, Long TW, Corday E, et al.  Consequences of reperfusion following acute coronary occlusion.  In: Roy PE, Rona G, eds. Recent Advances in Studies on Cardiac Structures and Metabolism . Baltimore, Md: University Park Press; 1975;:423-433.
54 +
Astiz ME, Rackow EC, Falk JL, et al.  Oxygen delivery and consumption in patients with hyperdynamic septic shock. Crit Care Med . 1987;;15:26-28.
55 +
Astiz ME, Rackow EC, Kaufman B, et al.  Relationship of oxygen delivery and mixed venous oxygenation to lactic acidosis in patients with sepsis and acute myocardial infarction. Crit Care Med . 1988;;16:655-658.
56 +
Sheps DS, Conde C, Cameron B, et al.  Resting peripheral blood lactate elevation in survivors of prehospital cardiac arrest: correlation with hemodynamic, electrophysiologic, and oxyhemoglobin dissociation indexes. Am J Cardiol . 1979;;44:1276-1282.
57 +
Kessler KM, Kozlovskis P, Trohman RG, Myerburg RJ.  Serulactate: prognostic marker for recurrent cardiac arrest? Am Heart J . 1987;;113:1540-1544.
58 +
Weil MH, Michaels S, Rackow EC.  Comparison of blood lactate concentrations in central venous, pulmonary artery, and arterial blood. Crit Care Med . 1987;;15:489-490.
59 +
Nimmo GR, Armstrong IR, Grant IS.  Sampling site for blood lactate estimation: arterial or mixed venous? Clin Intensive Care . 1993;;4:8-9.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Gaglio G.  Die Milchsaure des Blutes und ihre Ursprungsstatten. Arch Anat Physiol Abt . 1886;; 10:400-414.
2 +
Barker SB, Summerson WH.  The colorimetric determination of lactic acid in biological material. J Biol Chem . 1941;;138:535-545.
3 +
Broder G, Weil MH.  Excess lactate: an index of reversibility of shock in human patients. Science . 1964;;143:1457-1459.
4 +
Racine P, Klenk HO, Kochsiek K.  Rapid lactate determination with an electrochemical enzymatic sensor: clinical usability and comparative measurements. Z Klin Chem Klin Biochem . 1975;;13:533-539.
5 +
Ronco JJ, Fenwick JC, Wiggs BR, et al.  Oxygen consumption is independent of increases in oxygen delivery by dobutamine in septic patients who have normal or increased plasma lactate. Am Rev Respir Dis . 1993;;147:25-31.
6 +
Bishop MH, Shoemaker WC, Appel PL, et al.  Relationship between supranormal circulatory values, time delays, and outcome in severely traumatized patients. Crit Care Med . 1993;;21:56-63.
7 +
Shoemaker WC, Appel PL, Kram HB.  Hemodynamic and oxygen transport responses in survivors and nonsurvivors of high-risk surgery. Crit Care Med . 1993;;21:977-990.
8 +
Fleming A, Bishop M, Shoemaker W, et al.  Prospective trial of supranormal values as goals of resuscitation in severe trauma. Arch Surg . 1992;; 127:1175-1181.
9 +
Ronco JJ, Fenwick JC, Tweeddale MG, et al.  Identification of the critical oxygen delivery for anaerobic metabolism in critically ill septic and nonseptic humans. JAMA . 1993;;270:1724-1730.
10 +
Abramson D, Scalea TM, Hitchcock R, et al.  Lactate clearance and survival following injury. J Trauma . 1993;;35:584-589.
11 +
Chernow B.  The bedside laboratory. Chest . 1990;; 97:183S-184S.
12 +
Salem M, Chernow B, Burke R, Stacey J, Slogoff M, Sood S.  Bedside diagnostic blood testing: its accuracy, rapidity, and utility in blood conservation. JAMA . 1991;;266:382-389.
13 +
Chernow B, Salem M, Stacey J.  Blood conservation: a critical care imperative. Crit Care Med . 1991;;19:313-314.
14 +
Chernow B.  Blood conservation in critical care: the evidence accumulates. Crit Care Med . 1993;;21: 481-482.
15 +
Schoen I, Graham GA, Custer E, Bandi Z, Georgewill D.  Clinically useful limits (CUL) criteria as a basis for quality control including minimal and optimal goals for quality control. Am J Clin Pathol . 1989;;91:172-181.
16 +
Bernstein WK, Aduen J, Bhatiani A, et al.  Simultaneous arterial and venous lactate determinations in critically ill patients. Crit Care Med . 1994;; 22:A227. Abstract.
17 +
Bland JM, Altman DG.  Statistical methods for assessing agreement between two methods of clinical measurement. Lancet . 1986;;1:307-310.
18 +
Greenburg AG.  Is survival related to failure in oxygen delivery? Crit Care Med . 1993;;21:954.
19 +
Silverman HJ.  Lack of a relationship between induced changes in oxygen consumption and changes in lactate levels. Chest . 1991;;100:1012-1015.
20 +
Kruse JA, Haupt MT, Puri VK, Carlson RW.  Lactate levels as predictors of the relationship between oxygen delivery and consumption in ARDS. Chest . 1990;;98:959-962.
21 +
Nimmo GR, Mackenzie SJ, Walker SW, et al.  The relationship of blood lactate concentrations, oxygen delivery, and oxygen consumption in septic shock and the adult respiratory distress syndrome. Anaesthesia . 1992;;47:1023-1028.
22 +
Toffaletti J, Hammes ME, Gray R, et al.  Lactate measured in diluted and undiluted whole blood and plasma: comparison of methods and effect of hematocrit. Clin Chem . 1992;;38:2430-2434.
23 +
Prentice A, Vagdama P, Dunlop W.  Changes in plasma and whole blood lactate in response to arterial occlusion. Intensive Care Med . 1990;;16:28-32.
24 +
Kruse JA, Carlson RW.  Lactate measurement: plasma or blood? Intensive Care Med . 1990;;16:1-2.
25 +
Huckabee WE.  Abnormal resting blood lactate. Am J Med . 1961;;30:833-839.
26 +
Rashkin MC, Bosken C, Baughman RP.  Oxygen delivery in critically ill patients: relationship to blood lactate and survival. Chest . 1985;;87:580-584.
27 +
Blair E, Cowley RA, Tait MK.  Refractory septic shock in man: role of lactate and pyruvate metabolism and acid-base balance in prognosis. Am Surg . 1965;;31:537-540.
28 +
Weil MH, Ruiz CE, Michaels S, Rackow EC.  Acid-base determinants of survival after cardiopulmonary resuscitation. Crit Care Med . 1985;;13: 888-892.
29 +
Henning RJ, Weil MH, Weiner F.  Blood lactate as a prognostic indicator of survival in patients with acute myocardial infarction. Circ Shock . 1982;;9:307-315.
30 +
Perret C, Enrico JF.  Lactate in acute circulatory failure.  In: Bossart H, Perret C, eds. Lactate in Acute Conditions . New York, NY: S Karger; 1979;:69-82.
31 +
Weil MH, Afifi AA.  Experimental and clinical studies on lactate and pyruvate as indicators of the severity of acute circulatory failure. Circulation . 1970;;41:989-1001.
32 +
Bakker J, Coffernils M, Leon M, et al.  Blood lactate levels are superior to oxygen-derived variables in predicting outcome in human septic shock. Chest . 1991;;99:956-962.
33 +
Parker MM, Shelhamer JH, Natanson C, et al.  Serial cardiovascular variables in survivors and nonsurvivors of human septic shock: heart rate as an early predictor of prognosis. Crit Care Med . 1987;; 15:923-929.
34 +
Tuchschmidt J, Fried J, Swinney R, Sharma OMP.  Early hemodynamic correlates of survival in patients with septic shock. Crit Care Med . 1989;; 17:719-723.
35 +
Siegel JH, Rivkind AI, Dalal S, Goodarzi S.  Early physiologic predictors of injury severity and death in blunt multiple trauma. Arch Surg . 1990;; 125:498-508.
36 +
Vincent JL, Dufaye P, Berre J, et al.  Serial lactate determinations during circulatory shock. Crit Care Med . 1983;;11:449-451.
37 +
Peretz DI, McGragor M, Dossetor JB.  Lactic acidosis: a clinically significant aspect of shock. Can Med Assoc J . 1964;;90:673-675.
38 +
Cowan BN, Burns HJG, Boyle P, Ledingham MCA.  The relative prognostic value of lactate and hemodynamic measurements in early shock. Anaesthesia . 1984;;39:759-755.
39 +
Schuster HP.  Prognostic value of blood lactate in critically ill patients. Resuscitation . 1984;;11:141-146.
40 +
Falk JL, Rackow EC, Leavy J, et al.  Delayed lactate clearance in patients surviving circulatory shock. Acute Care . 1985;;11: 212-215.
41 +
Cady L, Weil MH, Afifi A, et al.  Quantification of severity of critical illness with special reference to blood lactate. Crit Care Med . 1973;;1:75-80.
42 +
Mavric Z, Zaputovic L, Zagar D, et al.  Usefulness of blood lactate as a predictor of shock development in acute myocardial infarction. Am J Cardiol . 1991;;67:565-568.
43 +
Groeneveld ABJ, Kester ADM, NautaJJP, Thijs LG.  Relation of arterial blood lactate to oxygen delivery and hemodynamic variables in human shock states. Circ Shock . 1987;;22:35-53.
44 +
Dunham CM, Siegel JH, Weireter L, et al.  Oxygen debt and metabolic acidemia as quantitative predictors of mortality and the severity of the ischemic insult in hemorrhagic shock. Crit Care Med . 1991;;19:231-243.
45 +
Gutierrez G, Bismar H, Dantzker DR, Silva N.  Comparison of gastric intramucosal pH with measures of oxygen transport and consumption in critically ill patients. Crit Care Med . 1992;;20:451-457.
46 +
Roumen RMH, Redl H, Schlag G, et al.  Scoring systems and blood lactate concentrations in relation to the development of adult respiratory distress syndrome and multiple organ failure in severely traumatized patients. J Trauma . 1993;;35: 349-355.
47 +
Stacpoole PW.  Lactic acidosis. Endocrinol Metab Clin North Am . 1993;;22:221-245.
48 +
Hotchkiss RS, Karl IE.  Reevaluation of the role of cellular hypoxia and bioenergetic failure in sepsis. JAMA . 1992;;267:1503-1510.
49 +
Schimassek H.  Lactate metabolism in the isolated perfused rat liver. Ann N Y Acad Sci . 1965;; 119:1013-1028.
50 +
Almenoff PL, Leavy J, Weil MH, et al.  Prolongation of the half-life of lactate after maximal exercise in patients with hepatic dysfunction. Crit Care Med . 1989;;17:870-873.
51 +
Landow L.  Splanchnic lactate production in cardiac surgery patients. Crit Care Med . 1993;;21( (suppl) ): S84-S91.
52 +
Leavy JA, Weil MH, Rackow EC.  'Lactate washout' following circulatory arrest. JAMA . 1988;;260: 662-664.
53 +
Meerbaum S, Long TW, Corday E, et al.  Consequences of reperfusion following acute coronary occlusion.  In: Roy PE, Rona G, eds. Recent Advances in Studies on Cardiac Structures and Metabolism . Baltimore, Md: University Park Press; 1975;:423-433.
54 +
Astiz ME, Rackow EC, Falk JL, et al.  Oxygen delivery and consumption in patients with hyperdynamic septic shock. Crit Care Med . 1987;;15:26-28.
55 +
Astiz ME, Rackow EC, Kaufman B, et al.  Relationship of oxygen delivery and mixed venous oxygenation to lactic acidosis in patients with sepsis and acute myocardial infarction. Crit Care Med . 1988;;16:655-658.
56 +
Sheps DS, Conde C, Cameron B, et al.  Resting peripheral blood lactate elevation in survivors of prehospital cardiac arrest: correlation with hemodynamic, electrophysiologic, and oxyhemoglobin dissociation indexes. Am J Cardiol . 1979;;44:1276-1282.
57 +
Kessler KM, Kozlovskis P, Trohman RG, Myerburg RJ.  Serulactate: prognostic marker for recurrent cardiac arrest? Am Heart J . 1987;;113:1540-1544.
58 +
Weil MH, Michaels S, Rackow EC.  Comparison of blood lactate concentrations in central venous, pulmonary artery, and arterial blood. Crit Care Med . 1987;;15:489-490.
59 +
Nimmo GR, Armstrong IR, Grant IS.  Sampling site for blood lactate estimation: arterial or mixed venous? Clin Intensive Care . 1993;;4:8-9.

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