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JOURNAL CLUB | GASTROINTESTINAL Evaluation of Initial Plasma Lactate Values as a Predictor of Gastric Necrosis and Initial and Subsequent Plasma Lactate Values as a Predictor of Survival in Dogs with Gastric Dilatation-Volvulus: 84 Dogs (2003-2007) Green TI, Tonozzi CC, Kirby R, et al. Journal of Veterinary Emergency and Critical Care 2011; 21(1):36-44. This study revisited the utility of lactate measurements in predicting gastric necrosis. Gastric necrosis that necessitates resection is associated with an increased mortality rate in dogs with gastric dilatation-volvulus (GDV). One study, by De Papp and colleagues in 1999, established that a lactate value of > 6 mmol/L has an 88% specificity for predicting gastric necrosis and subsequent increased risk of death. However, in the last 10 years, this figure of 6 mmol/L has been mistakenly quoted as a point where death is more likely, and this has lead to euthanizing dogs based upon initial lactate levels, rather than more objective and appropriate criteria. This study challenged this belief by re-evaluating the presenting lactate and also introducing lactate clearance. Lactate clearance is the rate of decline in lactate level over time and, in humans, increasing rates of lactate clearance are considered positive predictive values. For example, if 2 dogs present with a lactate level of 11 mmol/L plus a diagnosis of GDV and, after 2 hours of therapy, 1 dog’s lactate value has decreased to 9.8 mmol/L and the second dog’s lactate value has decreased to 3.2 mmol/L, the second dog, with the higher lactate clearance, can be predicted to have a better outcome. The results of this study supported that an initially high lactate level was more predictive of gastric necrosis; however, a cut-off of > 2.9 mmol/L predicted necrosis and > 4.1 mmol/L predicted death. Additionally, the study identified a 75% mortality rate in dogs that failed to decrease their initial elevated lactate level by more than 50% within 12 hours of presentation. This study is helpful for the clinician on 2 fronts: Key Considerations r 5IJT TUVEZ SFWJTJUFE UIF VUJMJUZ PG MBDUBUF measurements in predicting gastric necrosis and mortality rates in dogs with GDV. r 5IF SFTVMUT PG UIJT TUVEZ JOEJDBUFE UIBU BO JOJUJBMMZ high lactate was more predictive of gastric necrosis; a cut-off of >2.9 mmol/L predicted necrosis and > 4.1 mmol/L predicted death. r *O BEEJUJPO EPHT UIBU GBJMFE UP EFDSFBTF UIFJS JOJUJBM elevated lactate level by more than 50% had a 75% mortality rate. r *O EPHT XJUI (%7 FVUIBOBTJB TIPVME OPU CF BVUP matically recommended at a certain lactate value. 1. It confirms and clarifies the predictive values of initial lactate measurements. 2. It introduces the role of lactate clearance in GDV cases. Most important, the clinician should recall that predictions are valid for a group of patients, and less so the individual dog. Euthanasia should not be automatically recommended at a certain lactate value in dogs with GDV. —Elizabeth Rozanski, DVM, Diplomate ACVECC & ACVIM (Small Animal Internal Medicine), Tufts University Send us your commentaries & requests for Journal Club Would you like to provide a commentary on an article you feel would be of interest to fellow veterinarians? Or prefer to have a specialist comment on an article you’ve recently read? If so, email ksoldavin@ todaysveterinarypractice.com for guidelines on how to submit your commentary or request to Today’s Veterinary Practice. Would you like to read more? Go to todaysveterinarypractice.com for links to the articles featured in the Journal Club commentaries. July/August 2011 Today’s Veterinary Practice 79 Commentaries on Veterinary & Medical Literature