Morning Report: Double Digit Lactate

What do you do with a double digit lactate? Sepsis almost never gives you a lactate >10!

1) If Lactate is greater than 10 immediately think:

• lab error

• seizure

• ischemia (necrosis, compartment syndrome, shock liver)

• metformin toxicity

• thiamine deficiency

• toxic alcohols

• cyanide toxicity

2) Isopropanol is the "weird one out" for toxic alcohols - it elevates osmolality gap, but NOT anion gap. It does not cause an acidosis (methanol, ethylene glycol WILL cause HAGMA)

• Must know the above for board exams but in reality osmolality gap is not very useful

• Serial anion gaps is more sensitive for toxic alcohols

3) If the lactate on the VBG or the ABG is much higher than serum lactate, this is known as LACTATE GAP

• this is due to differences in the tests, but it is very specific for ETHYLENE GLYCOL poisoning

- Austin Parish

Lost to follow up, unknown CD4, unknown viral count...should we cover?

***REPUBLISHED***

Yes this is lazy of me but I found this to be an interesting post. A ways back there was a man with a dream of a blog. This too is currently present and that man who currently has that dream of a blog is searching for content. This is content; it’s good content; however it’s not original content. More original content to come soon but in the mean time: a repeated morning report…

Credit to previous residents for the following information which was presented during a morning Report

THE CBC – PERHAPS A BASTION FOR THE INTELLECTUALLY ASTUTE?

If a patient’s CD4 count is unknown, the Absolute Lymphocyte Count (ALC) can act as a temporary surrogate.

ALC= WBC x % of Lymphocytes.

Here’s a quick review of the literature:

One of the more highly quoted studies states a CD4 count of <200 × 10(6) cells/μL is very likely if the ED ALC is <950 × 10(6) cells/μL and less likely if the ALC is >1,700 × 10(6) cells/μL, Napoli et al (2011).

Two studies performed in non-ED setting showed a good correlation between the CD4 count and ALC. There is some question as to whether these results are applicable or generalizable to the ED population, since all of the participants were tested during routine examinations, not while they were acutely ill, Blatt et al (1993) and Fournier AM et al (1993).

Another study, from Temple University, looked at 800+ samples of CBC + CD4 on HIV+ pt’s (ED & non-ED), Shapiro NI et al (1998).

While a single ALC threshold was neither sensitive nor specific for a low CD4 count, the investigators determined two valuable cut-offs of 1000 and 2000 cells/mm3.

– An ALC less than 1000 cells/mm3 was 91% predictive in identifying patients with CD4 counts less than 200 cells/mm3 (sensitivity only 67%, but specificity 96%).
– An ALC greater than 2000 cells/mm3 was 95% predictive in identifying CD4 counts greater than 200 cells/mm3.
The authors concluded that patients with ALCs greater than 2000 cells/mm3 might be less susceptible to opportunistic infections, while those with ALCs less than 1000 cells/mm3 are at higher risk. These researchers had no access to clinical data and couldn’t account for factors such as antiretroviral therapy or the presence of acute infection such as sepsis, pneumonia, or TB.

There are of course other studies which show the ALC isn’t great
Pirzada et al (2006), and others where it is decent.

These analyses of the ALC could prove useful in many resource poor areas of the world with rising rates of HIV/AIDS as shown by these studies in India and Africa, for example.

"Laryngoscope as a MURDER WEAPON" - Summary of Emcrit Podcast

VENTILATIONMedication Choices
Induction Agents - #1 priority is keeping them alive (pain, memory, awareness are #2,#3, #4)
**Remember, all sedatives will drop BP in shock patients**
They are freaking out right before intubation, so when you knock them out, you lose those sympathetics (9 inch nails becomes Bob Marley)
Going negative to positive pressure ventilation causing reduced preload
Propofol “sometimes the white just ain’t right” dose reduced 90% (150 -->15mg in shocky patient)
Etomidate - ignoring the steroid suppression debate, he says you need MORE etomidate to get same levels in the brain in a shock patient (Singer may disagree here) - Weingart doesn’t use etomidate because if you ½ the dose they may be aware, and remember you eek!
Midazolam +/- fentanyl - effects are 3-5 minutes, so no effect during RSI, then after intubated will have some effect (praying for retrograde amnesia) AVOID!, Ok maybe give low dose versed 3-5 minutes before intubating
Ketamine, LOVE IT, gives a sympathetic surge.
- Pain Dosing .1-.2mg/kg
- Middle ground - Perfect for shocky patient intubation so maybe 30-50 IV??
- Dissociative dose - 1-2mg/kg (so 70-140 IV, or 210-300 IM)
Faster onset than propofol/etomidate, so you will see effects IMMEDIATELY
It’s also an analgesic! And good for TBI! (if shocky)Let’s Talk Paralytics
These also have a longer time of onset in a shocky patient (onset is cardiac output dependent)
Dose higher (remember sedatives go low!)
PRETREAT - Scopolamine .4mg IVP 10-15 minutes beforehand, only side effect is tachycardia, which is perfect.
Ketamine ½ dose - .5mg/kg, so 35mg in a 70kg patient
High dose of Succ (2mg/kg) or Roc (1.6mg/kg) so 140Succ or 112RocPeri-intubation
Give fluids (shoot for higher than normal BP because you will drop it during RSI), shoot for systolic 140, MAP 80
So start on inopressor drip before intubating (if NE drip needed), or even just hook them up, set pump at 0, if they start to drop BOOM pump started, also have push dose pressor (Epinephrine) ready before intubation, Not Phenyl!Vent Settings
Start low on pressures/PEEP
6cc/Kg TV (420 in 70 kg patient)
DSI
Push small amount of ketamine to check BP drop (but won’t stop their breathing), push 20, some patients only need 20, then paralytic, then tube!
Now if they drop with 20, know you need more pressor support (fluids, NE drip/push dose) (

SCAPE - Summary of EMCRIT Podcast

#1 - SCAPE aka severe acute pulmonary edemaThe Game: You've got 2 minutes before you intubate them, what do you do before they "buy some plastic"??!!
PE: SBP>180, rales bilaterally
For gods sakes throw the lasix in the trash (most patient's are volume depleted, not overloaded)
Step 1: Place BIPAP mask, start PEEP at 6-8, quickly titrate to PEEP 10-12
Step 2: Get IV, need loading dose of Nitro BEFORE drip. So run 400mcg/min for 2 min, then knock down to 100 and titrate up. Can give 2mg bolus if necessary.
Step 3: Once they are out of the woods, to get rid of drip give enalapril or SL captopril. To make medicine happy I'll toss 40 or 80 of lasix at the end to make them happy, but trust me, its not for me.Caveats:
- Nurse won't give drip because rate is too high? "Please step aside, I'll take over"
- "Doc, this mask is FREAKING ME OUT", given them 25-50 fentanylIf you intubate, you have FAILED!Extra nugs:
- 1-2mg of nitro has been shown to be safe
- In a prospective cohort study at Mt. Sinai, they gave on average 1.5mg nitro with ZERO patients needing intubation, 2 had SBP dip under 100 but that resolved spontaneously.
- SL Nitro (this is just my opinion) is useless. Its 400 mcg, but dissolves in 5 minutes, so its really 80 mcg/min, if its EVEN dissolving in that dry mouth. No real thoughts on nitro paste as I never use it. (edited)

EtCO2 - Why? What? How? (Summary of EMCRIT podcast)

Myth: ETCO2=PaCO2, in fact it’s EtCO2 = PaCO2 AND Deadspace in Lungs (from poor perfusion/Cardiac Output), so basically the deadspace in the lungs will lower the overall EtCO2 (by diluting the PaCO2)
What does this mean? EtCO2 < PaCO2, so if EtCO2 ~ 60 means we need increased ventilation, but EtCO2 ~20 means what exactly? NOTHING! PaCO2 could be 22 or 105.So when is it helpful?
1. ET tube confirmation2. If spike in EtCO2 during cardiac arrest (like 12 → 48), check pulse! (remember its Cardiac Output as well!). On flipside, if EtCO2 is <10 at 20min mark, chance of survival is low.3. Procedural Sedation
If supplemental O2 used, SpO2 (pulse ox) is USELESS for measuring ventilatory status (won’t desat until they’ve been apenic for a while)
Can see when patient is apneic4. Brain trauma (TBI)
Intubated patient has EtCO2 of 50, means PaCO2 is at least 50, need to increase ventilation (lowers CO2 → vasoconstriction in brain -->decreased swelling). Again, if 20, means nothing?? So wait until EtCO2 is lower than 35 before sending blood gas!5 Intubation with Acidosis (DKA, aspirin)
See baseline EtCO2, then don’t let it rise during intubation
During RSI, bag, then after tubed immediately to get EtCO2 to at least your baseline pre-intubation.
Maybe drip bicarb in before intubation, anyone remember how to correctly do that?Where is it NOT helpful
Can’t use to estimate respiratory status (aka what is the PaCO2), since it measures CO and PaCO2.What about color change devices??
Quickest/easiest way to confirm tube in non-cardiac arrest patient
Needs to stay yellow after 6 breaths, not 2.
Vomit gives false positive
Epi in ET tube will change it yellow
Doesn’t work in Cardiac Arrest (use direct laryngoscopy or use quantitative device) (edited)