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Rising Lactate Despite Source Control — FRCA Final MCQ

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ModerateIntensive Care MedicineRising Lactate Despite Source ControlFRCA Final

A 75-year-old man (ASA IV) undergoes an emergency Hartmann's procedure for perforated sigmoid diverticulitis. He has a pre-operative lactate of 6.5 mmol/L. Post-operatively in ICU, despite source control, antibiotics, and goal-directed fluid therapy, his lactate rises to 9.5 mmol/L at 6 hours. What does a rising lactate despite source control most likely indicate?

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Correct answer: E — Persistent tissue hypoperfusion or inadequate resuscitation requiring reassessment of DO2

A rising lactate despite appropriate source control and resuscitation indicates persistent tissue hypoperfusion. The SSC guidelines emphasise that lactate normalisation guides resuscitation adequacy. A rising lactate at 6 hours suggests: inadequate cardiac output (consider inotropes, echocardiography), persistent hypovolaemia (further fluid assessment), ongoing sepsis (review antibiotics, consider missed source), or mesenteric ischaemia (CT angiography). Alternatively, impaired lactate clearance (liver dysfunction) should be considered. This patient requires urgent reassessment of all aspects of oxygen delivery.

Reference: SSC – 2021 – Sepsis guidelines; RCOA – 2023 – ICM resuscitation endpoints