A (happy) error:
OR why you should “mind the gap”
Peter Brindley
Full Time Critical Care Doc
Other Stuff:
MD, FRCPC, FRCP-Edin, FRCP-Lond
Professor, Critical Care Medicine, Medical Ethics, Anesthesiology
brindley@ualberta.ca/@docpgb

Would the other Dr Brindley please
“stand up”
Dr Giles Brindley.
not related!
“Brindley dropped his pants before the audience
…a very respectable erection”

Our sensitive friend, Lactate
”
Impending collapse
Vulnerable patient
Early warning
Sensitive
Cheap
Immediate

• 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)

Case 2
• 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

Scientific Method

Using Brindley blood
• Added EG metabolites:
– Glycolate, Glyoxalate, Oxalate, (Formate).
• Tested on 5 common analyzers:
– Radiometer (POC),
– Beckman (lab),
– Vitros (lab)
– Bayer, (POC)
– Istat (POC)

EG NOT MT

Insert Heritage Picture
CMAJ 2007: 176(8): 1097
Q.E.D

And enjoy the gap

Many thx
Now please disagree
brindley@ualberta.ca
@docpgb