Pacient maacute vysokyacute laktaacutet ale nemaacute klinickeacute znaacutemky tkaacuteňoveacute

hypoperfuze Vladimiacuter Šraacutemek

ARK FN u svateacute Anny v Brně

XXI Kongres ČSARIM Olomouc 2-492014

laktaacutet a prognoacuteza

laktaacutet a ICU

bull laktaacutet 21ndash39 je spojen s vyššiacute mortalitou (Trzeciak ICM 2007)

bull laktaacutet 14-23 u SŠ je spojen s vyššiacute mortalitou (VASST subanalyacuteza ndash Wacharasint Shock 2012)

bull vyššiacute laktaacutet bez hypotenze spojen s vyššiacute mortalitou (Howell ICM 2007)

bull ale hypotenze bez zvyacutešeneacuteho laktaacutetu (lt 25) maacute dobrou prognoacutezu (Hernandez Resuscitation 2011)

Early Lactate-Guided Therapy in ICU Patients A Multicenter Open-Label Randomized Controlled Trial Am J Resp Crit Care Med 2010 May 12 [Epub ahead of print]

Jansen TC et al Bakker J for the LACTATE Study Group OBJECTIVE To assess the effect of lactate monitoring and resuscitation directed at decreasing lactate

levels in ICU patients admitted with a lactate level of gt= 30 mEql bull METHODS to decrease lactate by gt= 20 per two hours for the initial 8 hours of ICU stayhellip bull MEASUREMENTS AND MAIN RESULTS The lactate group received more fluids and vasodilators

However there were no significant differences in lactate levels between the groups In the intention-to-treat population (348 patients) hospital mortality in the control group was 435 (77177) compared with 339 (58171) in the lactate group (p=0067) When adjusted for predefined risk factors hospital mortality was lower in the lactate group (hazard ratio 061 95CI 043-087 p=0006)

bull CONCLUSIONS In patients with hyperlactatemia on ICU admission lactate-guided therapy significantly reduced hospital mortality when adjusting for predefined risk factors

clearance laktaacutetu

laktaacutet a prognoacuteza

laktaacutet a ICU

bull laktaacutet 21ndash39 je spojen s vyššiacute mortalitou (Trzeciak ICM 2007)

bull laktaacutet 14-23 u SŠ je spojen s vyššiacute mortalitou (VASST subanalyacuteza ndash Wacharasint Shock 2012)

bull vyššiacute laktaacutet bez hypotenze spojen s vyššiacute mortalitou (Howell ICM 2007)

bull ale hypotenze bez zvyacutešeneacuteho laktaacutetu (lt 25) maacute dobrou prognoacutezu (Hernandez Resuscitation 2011)

Early Lactate-Guided Therapy in ICU Patients A Multicenter Open-Label Randomized Controlled Trial Am J Resp Crit Care Med 2010 May 12 [Epub ahead of print]

Jansen TC et al Bakker J for the LACTATE Study Group OBJECTIVE To assess the effect of lactate monitoring and resuscitation directed at decreasing lactate

levels in ICU patients admitted with a lactate level of gt= 30 mEql bull METHODS to decrease lactate by gt= 20 per two hours for the initial 8 hours of ICU stayhellip bull MEASUREMENTS AND MAIN RESULTS The lactate group received more fluids and vasodilators

However there were no significant differences in lactate levels between the groups In the intention-to-treat population (348 patients) hospital mortality in the control group was 435 (77177) compared with 339 (58171) in the lactate group (p=0067) When adjusted for predefined risk factors hospital mortality was lower in the lactate group (hazard ratio 061 95CI 043-087 p=0006)

bull CONCLUSIONS In patients with hyperlactatemia on ICU admission lactate-guided therapy significantly reduced hospital mortality when adjusting for predefined risk factors

clearance laktaacutetu

laktaacutet a ICU

bull laktaacutet 21ndash39 je spojen s vyššiacute mortalitou (Trzeciak ICM 2007)

bull laktaacutet 14-23 u SŠ je spojen s vyššiacute mortalitou (VASST subanalyacuteza ndash Wacharasint Shock 2012)

bull vyššiacute laktaacutet bez hypotenze spojen s vyššiacute mortalitou (Howell ICM 2007)

bull ale hypotenze bez zvyacutešeneacuteho laktaacutetu (lt 25) maacute dobrou prognoacutezu (Hernandez Resuscitation 2011)

Early Lactate-Guided Therapy in ICU Patients A Multicenter Open-Label Randomized Controlled Trial Am J Resp Crit Care Med 2010 May 12 [Epub ahead of print]

Jansen TC et al Bakker J for the LACTATE Study Group OBJECTIVE To assess the effect of lactate monitoring and resuscitation directed at decreasing lactate

levels in ICU patients admitted with a lactate level of gt= 30 mEql bull METHODS to decrease lactate by gt= 20 per two hours for the initial 8 hours of ICU stayhellip bull MEASUREMENTS AND MAIN RESULTS The lactate group received more fluids and vasodilators

However there were no significant differences in lactate levels between the groups In the intention-to-treat population (348 patients) hospital mortality in the control group was 435 (77177) compared with 339 (58171) in the lactate group (p=0067) When adjusted for predefined risk factors hospital mortality was lower in the lactate group (hazard ratio 061 95CI 043-087 p=0006)

bull CONCLUSIONS In patients with hyperlactatemia on ICU admission lactate-guided therapy significantly reduced hospital mortality when adjusting for predefined risk factors

clearance laktaacutetu

Early Lactate-Guided Therapy in ICU Patients A Multicenter Open-Label Randomized Controlled Trial Am J Resp Crit Care Med 2010 May 12 [Epub ahead of print]

Jansen TC et al Bakker J for the LACTATE Study Group OBJECTIVE To assess the effect of lactate monitoring and resuscitation directed at decreasing lactate

levels in ICU patients admitted with a lactate level of gt= 30 mEql bull METHODS to decrease lactate by gt= 20 per two hours for the initial 8 hours of ICU stayhellip bull MEASUREMENTS AND MAIN RESULTS The lactate group received more fluids and vasodilators

However there were no significant differences in lactate levels between the groups In the intention-to-treat population (348 patients) hospital mortality in the control group was 435 (77177) compared with 339 (58171) in the lactate group (p=0067) When adjusted for predefined risk factors hospital mortality was lower in the lactate group (hazard ratio 061 95CI 043-087 p=0006)

bull CONCLUSIONS In patients with hyperlactatemia on ICU admission lactate-guided therapy significantly reduced hospital mortality when adjusting for predefined risk factors

clearance laktaacutetu

laktaacutet gt 4 (3) mmolL

clearance gt10-20 za 2 hod (6-8 hod)

Pacient maacute vysokyacute laktaacutet ale nemaacute klinickeacute znaacutemky tkaacuteňoveacute hypoperfuze

Vladimiacuter Šraacutemek

ARK FN u svateacute Anny v Brně

XXI Kongres ČSARIM Olomouc 2-492014

glucose

pyruvate

KREBS

cycle

III - lactate clearance (liverhellip)

I - anaerobic metabolism

II - aerobic metabolism

lactate

BLOOD LACTATE LEVEL

H+

2e + O + 2H+

HYPOPERfUacuteZE hemodynamickaacute (makro + mikro) přiacutečina nefunkčniacuteho Krebs cy

I ndash energetickyacute kolaps (regionaacutelniacute hypoperfuze + mitochondrie)

Regionaacutelniacute hypoperfuze

(ShO2 DSF gastricPCO2)

Energetickyacute kolaps bez

hypoperfuze

bull PDH (thiamin)

bull mitochondriaacutelniacute dysfunkce

(cytopatickaacute hypoxie)

II ndash zvyacutešenaacute glykolyacuteza

szlig-2 adrenergniacute stimulace (salbutamol adrenalin) ndash zvyšuje aktivitu Na-K-ATPaacutezy

bull Levy B et al (2008) Increased aerobic glycolysis through beta-2 stimulation is a common mechanism involved in lactate formation during shock states SHOCK 4417-421

zvyacutešenaacute činnost leukocytů hojeniacute ranhellip glykolyacuteza zdrojem pro PPShunt

bull Bauer DE et al (2004) Cytokine stimulation of aerobic glycolysis in hematopoietic cells exceeds proliferative demand FASEB J 181303-5

III ndash porušenaacute clearance

Jaacutetra + ledviny glukoneogenesa Srdce mozek svaly a kůže oxidace

ANO bull Levraut J Ciebiera JP Chave S Rabary O Jambou P

Carles M Grimaud D (1998) Mild hyperlactatemia in stable septic patients is due to impaired lactate clearance rather than overproduction Am J Resp Crit Care Med 1561ndash6

NE bull Chioleacutero RL Revelly JP Leverve X Gersbach P Cayeux

MC Berger MM Tappy L (2000) Effects of cardiogenic shock on lactate and glucose metabolism after heart surgery Crit Care Med 283784-91 (60 oxidace vs 40 glukoneogeneza)

uacuteloha jater neniacute zaacutesadniacute bull Chioleacutero R Tappy L Gillet M Revelly JP Roth H

Cayeux C Schneiter P Leverve X (1999) Effect of major hepatectomy on glucose and lactate metabolism Ann Surg 229505-13

Coriho cyklus

časnaacute resuscitace SŠ

clearance (mlkghod) endogenniacute produkce (micromolkghod)

T1 T2 T1 T2

G65 283 (224-920) 345 (213-917) 1039 (293-1924) 1398 (320-2637)

G85 331 (135-384) 323 (154-521) 702 (242-3223) 761 (423-2708)

p 046 060 029 034

Suk P a kol AIM 2007 112 Na laktaacutet

zvlaacuteštniacute situace s vysokyacutem laktaacutetem

bull metformin

bull malignita

bull propofol

bull paracetamol

bull střevniacute ischeacutemie

bull status epilepticus

bull deficit thiaminu

bull D laktaacutet ndash sy kraacutetkeacuteho střeva

laktaacutet a acidoacuteza

metabolismus laktaacutetu vaacutezaacuten na bb energii bull redox potenciaacutel (NADH H+)NAD+

bull fosfaacutetovyacute potenciaacutel ATP(ADP x Pi)

bull pH (61 + log(HCO3-003 PaCO2

kyselina mleacutečnaacute ndash lactic acid

MAC je způsobena tvorbou H+ při hydrolyacuteze ATP a absenci ATP tvorby

H+ + pKa = 386

st po KPR

zaacutevěr

bull vyššiacute laktaacutet je signum mallum

bull vždy myslet na lokaacutelniacute hypoperfuzi (splanchnicus) i když nejsou celotěloveacuteklinickeacute znaacutemky hypoperfuze přiacutetomny (ScvO2 mottling score CRThellip)

bull je zaacuteroveň přiacutetomna MAC (spiacuteše nepřiacutenosneacute)

bull klinika jinaacute situace než hypoperfuze (thiamin MALA atd)

Pacient maacute vysokyacute laktaacutet ale nemaacute klinickeacute znaacutemky tkaacuteňoveacute hypoperfuze

Vladimiacuter Šraacutemek

ARK FN u svateacute Anny v Brně

XXI Kongres ČSARIM Olomouc 2-492014

glucose

pyruvate

KREBS

cycle

III - lactate clearance (liverhellip)

I - anaerobic metabolism

II - aerobic metabolism

lactate

BLOOD LACTATE LEVEL

H+

2e + O + 2H+

HYPOPERfUacuteZE hemodynamickaacute (makro + mikro) přiacutečina nefunkčniacuteho Krebs cy

I ndash energetickyacute kolaps (regionaacutelniacute hypoperfuze + mitochondrie)

Regionaacutelniacute hypoperfuze

(ShO2 DSF gastricPCO2)

Energetickyacute kolaps bez

hypoperfuze

bull PDH (thiamin)

bull mitochondriaacutelniacute dysfunkce

(cytopatickaacute hypoxie)

II ndash zvyacutešenaacute glykolyacuteza

szlig-2 adrenergniacute stimulace (salbutamol adrenalin) ndash zvyšuje aktivitu Na-K-ATPaacutezy

bull Levy B et al (2008) Increased aerobic glycolysis through beta-2 stimulation is a common mechanism involved in lactate formation during shock states SHOCK 4417-421

zvyacutešenaacute činnost leukocytů hojeniacute ranhellip glykolyacuteza zdrojem pro PPShunt

bull Bauer DE et al (2004) Cytokine stimulation of aerobic glycolysis in hematopoietic cells exceeds proliferative demand FASEB J 181303-5

III ndash porušenaacute clearance

Jaacutetra + ledviny glukoneogenesa Srdce mozek svaly a kůže oxidace

ANO bull Levraut J Ciebiera JP Chave S Rabary O Jambou P

Carles M Grimaud D (1998) Mild hyperlactatemia in stable septic patients is due to impaired lactate clearance rather than overproduction Am J Resp Crit Care Med 1561ndash6

NE bull Chioleacutero RL Revelly JP Leverve X Gersbach P Cayeux

MC Berger MM Tappy L (2000) Effects of cardiogenic shock on lactate and glucose metabolism after heart surgery Crit Care Med 283784-91 (60 oxidace vs 40 glukoneogeneza)

uacuteloha jater neniacute zaacutesadniacute bull Chioleacutero R Tappy L Gillet M Revelly JP Roth H

Cayeux C Schneiter P Leverve X (1999) Effect of major hepatectomy on glucose and lactate metabolism Ann Surg 229505-13

Coriho cyklus

časnaacute resuscitace SŠ

clearance (mlkghod) endogenniacute produkce (micromolkghod)

T1 T2 T1 T2

G65 283 (224-920) 345 (213-917) 1039 (293-1924) 1398 (320-2637)

G85 331 (135-384) 323 (154-521) 702 (242-3223) 761 (423-2708)

p 046 060 029 034

Suk P a kol AIM 2007 112 Na laktaacutet

zvlaacuteštniacute situace s vysokyacutem laktaacutetem

bull metformin

bull malignita

bull propofol

bull paracetamol

bull střevniacute ischeacutemie

bull status epilepticus

bull deficit thiaminu

bull D laktaacutet ndash sy kraacutetkeacuteho střeva

laktaacutet a acidoacuteza

metabolismus laktaacutetu vaacutezaacuten na bb energii bull redox potenciaacutel (NADH H+)NAD+

bull fosfaacutetovyacute potenciaacutel ATP(ADP x Pi)

bull pH (61 + log(HCO3-003 PaCO2

kyselina mleacutečnaacute ndash lactic acid

MAC je způsobena tvorbou H+ při hydrolyacuteze ATP a absenci ATP tvorby

H+ + pKa = 386

st po KPR

zaacutevěr

bull vyššiacute laktaacutet je signum mallum

bull vždy myslet na lokaacutelniacute hypoperfuzi (splanchnicus) i když nejsou celotěloveacuteklinickeacute znaacutemky hypoperfuze přiacutetomny (ScvO2 mottling score CRThellip)

bull je zaacuteroveň přiacutetomna MAC (spiacuteše nepřiacutenosneacute)

bull klinika jinaacute situace než hypoperfuze (thiamin MALA atd)

glucose

pyruvate

KREBS

cycle

III - lactate clearance (liverhellip)

I - anaerobic metabolism

II - aerobic metabolism

lactate

BLOOD LACTATE LEVEL

H+

2e + O + 2H+

HYPOPERfUacuteZE hemodynamickaacute (makro + mikro) přiacutečina nefunkčniacuteho Krebs cy

I ndash energetickyacute kolaps (regionaacutelniacute hypoperfuze + mitochondrie)

Regionaacutelniacute hypoperfuze

(ShO2 DSF gastricPCO2)

Energetickyacute kolaps bez

hypoperfuze

bull PDH (thiamin)

bull mitochondriaacutelniacute dysfunkce

(cytopatickaacute hypoxie)

II ndash zvyacutešenaacute glykolyacuteza

szlig-2 adrenergniacute stimulace (salbutamol adrenalin) ndash zvyšuje aktivitu Na-K-ATPaacutezy

bull Levy B et al (2008) Increased aerobic glycolysis through beta-2 stimulation is a common mechanism involved in lactate formation during shock states SHOCK 4417-421

zvyacutešenaacute činnost leukocytů hojeniacute ranhellip glykolyacuteza zdrojem pro PPShunt

bull Bauer DE et al (2004) Cytokine stimulation of aerobic glycolysis in hematopoietic cells exceeds proliferative demand FASEB J 181303-5

III ndash porušenaacute clearance

Jaacutetra + ledviny glukoneogenesa Srdce mozek svaly a kůže oxidace

ANO bull Levraut J Ciebiera JP Chave S Rabary O Jambou P

Carles M Grimaud D (1998) Mild hyperlactatemia in stable septic patients is due to impaired lactate clearance rather than overproduction Am J Resp Crit Care Med 1561ndash6

NE bull Chioleacutero RL Revelly JP Leverve X Gersbach P Cayeux

MC Berger MM Tappy L (2000) Effects of cardiogenic shock on lactate and glucose metabolism after heart surgery Crit Care Med 283784-91 (60 oxidace vs 40 glukoneogeneza)

uacuteloha jater neniacute zaacutesadniacute bull Chioleacutero R Tappy L Gillet M Revelly JP Roth H

Cayeux C Schneiter P Leverve X (1999) Effect of major hepatectomy on glucose and lactate metabolism Ann Surg 229505-13

Coriho cyklus

časnaacute resuscitace SŠ

clearance (mlkghod) endogenniacute produkce (micromolkghod)

T1 T2 T1 T2

G65 283 (224-920) 345 (213-917) 1039 (293-1924) 1398 (320-2637)

G85 331 (135-384) 323 (154-521) 702 (242-3223) 761 (423-2708)

p 046 060 029 034

Suk P a kol AIM 2007 112 Na laktaacutet

zvlaacuteštniacute situace s vysokyacutem laktaacutetem

bull metformin

bull malignita

bull propofol

bull paracetamol

bull střevniacute ischeacutemie

bull status epilepticus

bull deficit thiaminu

bull D laktaacutet ndash sy kraacutetkeacuteho střeva

laktaacutet a acidoacuteza

metabolismus laktaacutetu vaacutezaacuten na bb energii bull redox potenciaacutel (NADH H+)NAD+

bull fosfaacutetovyacute potenciaacutel ATP(ADP x Pi)

bull pH (61 + log(HCO3-003 PaCO2

kyselina mleacutečnaacute ndash lactic acid

MAC je způsobena tvorbou H+ při hydrolyacuteze ATP a absenci ATP tvorby

H+ + pKa = 386

st po KPR

zaacutevěr

bull vyššiacute laktaacutet je signum mallum

bull vždy myslet na lokaacutelniacute hypoperfuzi (splanchnicus) i když nejsou celotěloveacuteklinickeacute znaacutemky hypoperfuze přiacutetomny (ScvO2 mottling score CRThellip)

bull je zaacuteroveň přiacutetomna MAC (spiacuteše nepřiacutenosneacute)

bull klinika jinaacute situace než hypoperfuze (thiamin MALA atd)

I ndash energetickyacute kolaps (regionaacutelniacute hypoperfuze + mitochondrie)

Regionaacutelniacute hypoperfuze

(ShO2 DSF gastricPCO2)

Energetickyacute kolaps bez

hypoperfuze

bull PDH (thiamin)

bull mitochondriaacutelniacute dysfunkce

(cytopatickaacute hypoxie)

II ndash zvyacutešenaacute glykolyacuteza

szlig-2 adrenergniacute stimulace (salbutamol adrenalin) ndash zvyšuje aktivitu Na-K-ATPaacutezy

bull Levy B et al (2008) Increased aerobic glycolysis through beta-2 stimulation is a common mechanism involved in lactate formation during shock states SHOCK 4417-421

zvyacutešenaacute činnost leukocytů hojeniacute ranhellip glykolyacuteza zdrojem pro PPShunt

bull Bauer DE et al (2004) Cytokine stimulation of aerobic glycolysis in hematopoietic cells exceeds proliferative demand FASEB J 181303-5

III ndash porušenaacute clearance

Jaacutetra + ledviny glukoneogenesa Srdce mozek svaly a kůže oxidace

ANO bull Levraut J Ciebiera JP Chave S Rabary O Jambou P

Carles M Grimaud D (1998) Mild hyperlactatemia in stable septic patients is due to impaired lactate clearance rather than overproduction Am J Resp Crit Care Med 1561ndash6

NE bull Chioleacutero RL Revelly JP Leverve X Gersbach P Cayeux

MC Berger MM Tappy L (2000) Effects of cardiogenic shock on lactate and glucose metabolism after heart surgery Crit Care Med 283784-91 (60 oxidace vs 40 glukoneogeneza)

uacuteloha jater neniacute zaacutesadniacute bull Chioleacutero R Tappy L Gillet M Revelly JP Roth H

Cayeux C Schneiter P Leverve X (1999) Effect of major hepatectomy on glucose and lactate metabolism Ann Surg 229505-13

Coriho cyklus

časnaacute resuscitace SŠ

clearance (mlkghod) endogenniacute produkce (micromolkghod)

T1 T2 T1 T2

G65 283 (224-920) 345 (213-917) 1039 (293-1924) 1398 (320-2637)

G85 331 (135-384) 323 (154-521) 702 (242-3223) 761 (423-2708)

p 046 060 029 034

Suk P a kol AIM 2007 112 Na laktaacutet

zvlaacuteštniacute situace s vysokyacutem laktaacutetem

bull metformin

bull malignita

bull propofol

bull paracetamol

bull střevniacute ischeacutemie

bull status epilepticus

bull deficit thiaminu

bull D laktaacutet ndash sy kraacutetkeacuteho střeva

laktaacutet a acidoacuteza

metabolismus laktaacutetu vaacutezaacuten na bb energii bull redox potenciaacutel (NADH H+)NAD+

bull fosfaacutetovyacute potenciaacutel ATP(ADP x Pi)

bull pH (61 + log(HCO3-003 PaCO2

kyselina mleacutečnaacute ndash lactic acid

MAC je způsobena tvorbou H+ při hydrolyacuteze ATP a absenci ATP tvorby

H+ + pKa = 386

st po KPR

zaacutevěr

bull vyššiacute laktaacutet je signum mallum

bull vždy myslet na lokaacutelniacute hypoperfuzi (splanchnicus) i když nejsou celotěloveacuteklinickeacute znaacutemky hypoperfuze přiacutetomny (ScvO2 mottling score CRThellip)

bull je zaacuteroveň přiacutetomna MAC (spiacuteše nepřiacutenosneacute)

bull klinika jinaacute situace než hypoperfuze (thiamin MALA atd)

II ndash zvyacutešenaacute glykolyacuteza

szlig-2 adrenergniacute stimulace (salbutamol adrenalin) ndash zvyšuje aktivitu Na-K-ATPaacutezy

bull Levy B et al (2008) Increased aerobic glycolysis through beta-2 stimulation is a common mechanism involved in lactate formation during shock states SHOCK 4417-421

zvyacutešenaacute činnost leukocytů hojeniacute ranhellip glykolyacuteza zdrojem pro PPShunt

bull Bauer DE et al (2004) Cytokine stimulation of aerobic glycolysis in hematopoietic cells exceeds proliferative demand FASEB J 181303-5

III ndash porušenaacute clearance

Jaacutetra + ledviny glukoneogenesa Srdce mozek svaly a kůže oxidace

ANO bull Levraut J Ciebiera JP Chave S Rabary O Jambou P

Carles M Grimaud D (1998) Mild hyperlactatemia in stable septic patients is due to impaired lactate clearance rather than overproduction Am J Resp Crit Care Med 1561ndash6

NE bull Chioleacutero RL Revelly JP Leverve X Gersbach P Cayeux

MC Berger MM Tappy L (2000) Effects of cardiogenic shock on lactate and glucose metabolism after heart surgery Crit Care Med 283784-91 (60 oxidace vs 40 glukoneogeneza)

uacuteloha jater neniacute zaacutesadniacute bull Chioleacutero R Tappy L Gillet M Revelly JP Roth H

Cayeux C Schneiter P Leverve X (1999) Effect of major hepatectomy on glucose and lactate metabolism Ann Surg 229505-13

Coriho cyklus

časnaacute resuscitace SŠ

clearance (mlkghod) endogenniacute produkce (micromolkghod)

T1 T2 T1 T2

G65 283 (224-920) 345 (213-917) 1039 (293-1924) 1398 (320-2637)

G85 331 (135-384) 323 (154-521) 702 (242-3223) 761 (423-2708)

p 046 060 029 034

Suk P a kol AIM 2007 112 Na laktaacutet

zvlaacuteštniacute situace s vysokyacutem laktaacutetem

bull metformin

bull malignita

bull propofol

bull paracetamol

bull střevniacute ischeacutemie

bull status epilepticus

bull deficit thiaminu

bull D laktaacutet ndash sy kraacutetkeacuteho střeva

laktaacutet a acidoacuteza

metabolismus laktaacutetu vaacutezaacuten na bb energii bull redox potenciaacutel (NADH H+)NAD+

bull fosfaacutetovyacute potenciaacutel ATP(ADP x Pi)

bull pH (61 + log(HCO3-003 PaCO2

kyselina mleacutečnaacute ndash lactic acid

MAC je způsobena tvorbou H+ při hydrolyacuteze ATP a absenci ATP tvorby

H+ + pKa = 386

st po KPR

zaacutevěr

bull vyššiacute laktaacutet je signum mallum

bull vždy myslet na lokaacutelniacute hypoperfuzi (splanchnicus) i když nejsou celotěloveacuteklinickeacute znaacutemky hypoperfuze přiacutetomny (ScvO2 mottling score CRThellip)

bull je zaacuteroveň přiacutetomna MAC (spiacuteše nepřiacutenosneacute)

bull klinika jinaacute situace než hypoperfuze (thiamin MALA atd)

III ndash porušenaacute clearance

Jaacutetra + ledviny glukoneogenesa Srdce mozek svaly a kůže oxidace

ANO bull Levraut J Ciebiera JP Chave S Rabary O Jambou P

Carles M Grimaud D (1998) Mild hyperlactatemia in stable septic patients is due to impaired lactate clearance rather than overproduction Am J Resp Crit Care Med 1561ndash6

NE bull Chioleacutero RL Revelly JP Leverve X Gersbach P Cayeux

MC Berger MM Tappy L (2000) Effects of cardiogenic shock on lactate and glucose metabolism after heart surgery Crit Care Med 283784-91 (60 oxidace vs 40 glukoneogeneza)

uacuteloha jater neniacute zaacutesadniacute bull Chioleacutero R Tappy L Gillet M Revelly JP Roth H

Cayeux C Schneiter P Leverve X (1999) Effect of major hepatectomy on glucose and lactate metabolism Ann Surg 229505-13

Coriho cyklus

časnaacute resuscitace SŠ

clearance (mlkghod) endogenniacute produkce (micromolkghod)

T1 T2 T1 T2

G65 283 (224-920) 345 (213-917) 1039 (293-1924) 1398 (320-2637)

G85 331 (135-384) 323 (154-521) 702 (242-3223) 761 (423-2708)

p 046 060 029 034

Suk P a kol AIM 2007 112 Na laktaacutet

zvlaacuteštniacute situace s vysokyacutem laktaacutetem

bull metformin

bull malignita

bull propofol

bull paracetamol

bull střevniacute ischeacutemie

bull status epilepticus

bull deficit thiaminu

bull D laktaacutet ndash sy kraacutetkeacuteho střeva

laktaacutet a acidoacuteza

metabolismus laktaacutetu vaacutezaacuten na bb energii bull redox potenciaacutel (NADH H+)NAD+

bull fosfaacutetovyacute potenciaacutel ATP(ADP x Pi)

bull pH (61 + log(HCO3-003 PaCO2

kyselina mleacutečnaacute ndash lactic acid

MAC je způsobena tvorbou H+ při hydrolyacuteze ATP a absenci ATP tvorby

H+ + pKa = 386

st po KPR

zaacutevěr

bull vyššiacute laktaacutet je signum mallum

bull vždy myslet na lokaacutelniacute hypoperfuzi (splanchnicus) i když nejsou celotěloveacuteklinickeacute znaacutemky hypoperfuze přiacutetomny (ScvO2 mottling score CRThellip)

bull je zaacuteroveň přiacutetomna MAC (spiacuteše nepřiacutenosneacute)

bull klinika jinaacute situace než hypoperfuze (thiamin MALA atd)

časnaacute resuscitace SŠ

clearance (mlkghod) endogenniacute produkce (micromolkghod)

T1 T2 T1 T2

G65 283 (224-920) 345 (213-917) 1039 (293-1924) 1398 (320-2637)

G85 331 (135-384) 323 (154-521) 702 (242-3223) 761 (423-2708)

p 046 060 029 034

Suk P a kol AIM 2007 112 Na laktaacutet

zvlaacuteštniacute situace s vysokyacutem laktaacutetem

bull metformin

bull malignita

bull propofol

bull paracetamol

bull střevniacute ischeacutemie

bull status epilepticus

bull deficit thiaminu

bull D laktaacutet ndash sy kraacutetkeacuteho střeva

laktaacutet a acidoacuteza

metabolismus laktaacutetu vaacutezaacuten na bb energii bull redox potenciaacutel (NADH H+)NAD+

bull fosfaacutetovyacute potenciaacutel ATP(ADP x Pi)

bull pH (61 + log(HCO3-003 PaCO2

kyselina mleacutečnaacute ndash lactic acid

MAC je způsobena tvorbou H+ při hydrolyacuteze ATP a absenci ATP tvorby

H+ + pKa = 386

st po KPR

zaacutevěr

bull vyššiacute laktaacutet je signum mallum

bull vždy myslet na lokaacutelniacute hypoperfuzi (splanchnicus) i když nejsou celotěloveacuteklinickeacute znaacutemky hypoperfuze přiacutetomny (ScvO2 mottling score CRThellip)

bull je zaacuteroveň přiacutetomna MAC (spiacuteše nepřiacutenosneacute)

bull klinika jinaacute situace než hypoperfuze (thiamin MALA atd)

zvlaacuteštniacute situace s vysokyacutem laktaacutetem

bull metformin

bull malignita

bull propofol

bull paracetamol

bull střevniacute ischeacutemie

bull status epilepticus

bull deficit thiaminu

bull D laktaacutet ndash sy kraacutetkeacuteho střeva

laktaacutet a acidoacuteza

metabolismus laktaacutetu vaacutezaacuten na bb energii bull redox potenciaacutel (NADH H+)NAD+

bull fosfaacutetovyacute potenciaacutel ATP(ADP x Pi)

bull pH (61 + log(HCO3-003 PaCO2

kyselina mleacutečnaacute ndash lactic acid

MAC je způsobena tvorbou H+ při hydrolyacuteze ATP a absenci ATP tvorby

H+ + pKa = 386

st po KPR

zaacutevěr

bull vyššiacute laktaacutet je signum mallum

bull vždy myslet na lokaacutelniacute hypoperfuzi (splanchnicus) i když nejsou celotěloveacuteklinickeacute znaacutemky hypoperfuze přiacutetomny (ScvO2 mottling score CRThellip)

bull je zaacuteroveň přiacutetomna MAC (spiacuteše nepřiacutenosneacute)

bull klinika jinaacute situace než hypoperfuze (thiamin MALA atd)

laktaacutet a acidoacuteza

metabolismus laktaacutetu vaacutezaacuten na bb energii bull redox potenciaacutel (NADH H+)NAD+

bull fosfaacutetovyacute potenciaacutel ATP(ADP x Pi)

bull pH (61 + log(HCO3-003 PaCO2

kyselina mleacutečnaacute ndash lactic acid

MAC je způsobena tvorbou H+ při hydrolyacuteze ATP a absenci ATP tvorby

H+ + pKa = 386

st po KPR

zaacutevěr

bull vyššiacute laktaacutet je signum mallum

bull vždy myslet na lokaacutelniacute hypoperfuzi (splanchnicus) i když nejsou celotěloveacuteklinickeacute znaacutemky hypoperfuze přiacutetomny (ScvO2 mottling score CRThellip)

bull je zaacuteroveň přiacutetomna MAC (spiacuteše nepřiacutenosneacute)

bull klinika jinaacute situace než hypoperfuze (thiamin MALA atd)

st po KPR

zaacutevěr

bull vyššiacute laktaacutet je signum mallum

bull vždy myslet na lokaacutelniacute hypoperfuzi (splanchnicus) i když nejsou celotěloveacuteklinickeacute znaacutemky hypoperfuze přiacutetomny (ScvO2 mottling score CRThellip)

bull je zaacuteroveň přiacutetomna MAC (spiacuteše nepřiacutenosneacute)

bull klinika jinaacute situace než hypoperfuze (thiamin MALA atd)

zaacutevěr

bull vyššiacute laktaacutet je signum mallum

bull vždy myslet na lokaacutelniacute hypoperfuzi (splanchnicus) i když nejsou celotěloveacuteklinickeacute znaacutemky hypoperfuze přiacutetomny (ScvO2 mottling score CRThellip)

bull je zaacuteroveň přiacutetomna MAC (spiacuteše nepřiacutenosneacute)

bull klinika jinaacute situace než hypoperfuze (thiamin MALA atd)