A (happy) error:
OR why you should “mind the gap”
Full Time Critical Care Doc
MD, FRCPC, FRCP-Edin, FRCP-Lond
Professor, Critical Care Medicine, Medical Ethics, Anesthesiology
Would the other Dr Brindley please
Dr Giles Brindley.
“Brindley dropped his pants before the audience
…a very respectable erection”
• Pt intubted in ED d/t decr’d loc
• Sick (& pH<7) but not “lactate >40” sick
Case 1: Lactate >40 (x3)
• Minimal Hx
• Surgery prepared to operate
• To ICU for stabilization (& dx)
– Plasma/lab: lactate 1.5mmol/L; pH<7 (repeated)
– POC ABG (Bayer) lactate 2.0mmol/L; pH<7 (repeated)
– POC ABG (Radiometer) lactate 40mmol/L: pH<7 (repeated)
• Acidemia real; etiology “unreal”
Case 1: pH<7.0 WTF
“lactate Gap”= EG
• Increased Osm/ Osm gap
• Ethylene Gycol “rushed”…
…positive but took 2 hours
• Changed to IHD etc
• Patient recovered
– ICU x 7d, Dialysis x 14d
“Mind the gap”
• MIND THE (LACTATE) GAP:
– High false + lactate w Radiometer after EG
– But not with plasma or other POC
– Potential laparotomy (mortality)
– Potential delayed EG therapy (morbidity)
• POC lactate >20, pH <7.2// iStat lactate N.
• “lactate gap” 1st bedside Dx of EG
• Immediate IHD
• Extubated/discharged within 48h
• …Many other examples
– “Lactate gap” can be used for good!
– Important given
•Denial; strange ODs
•Late presentations; Consequences of delay
– & YOU NEED TWO ANALYZERS
N.B: Use all diagnostic clues
• Look at this table on e-Bay.
• How can you tell it is being sold by a man?
Look at the mirror…..
If you post a picture on the internet…..
WEAR CLOTHES when taking the picture!
No such thing as personal opinion…
David Brindley PhD, DSc, FRS etc etc