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Lactate in Critical Care: Mind the Gap!


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A (happy) error: Or why you should "mind the gap"

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Lactate in Critical Care: Mind the Gap!

  1. 1. 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
  2. 2. Would the other Dr Brindley please “stand up” Dr Giles Brindley. not related! “Brindley dropped his pants before the audience …a very respectable erection”
  3. 3. Our sensitive friend, Lactate ” Impending collapse Vulnerable patient Early warning Sensitive Cheap Immediate
  4. 4. • Pt intubted in ED d/t decr’d loc • Sick (& pH<7) but not “lactate >40” sick Case 1: Lactate >40 (x3)
  5. 5. • 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
  6. 6. “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
  7. 7. “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)
  8. 8. 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
  9. 9. – “Lactate gap” can be used for good! – Important given •Denial; strange ODs •Late presentations; Consequences of delay – & YOU NEED TWO ANALYZERS
  10. 10. N.B: Use all diagnostic clues • Look at this table on e-Bay. • How can you tell it is being sold by a man?
  11. 11. Look at the mirror….. If you post a picture on the internet….. WEAR CLOTHES when taking the picture!
  12. 12. No such thing as personal opinion… David Brindley PhD, DSc, FRS etc etc
  13. 13. Scientific Method
  14. 14. 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)
  15. 15. EG NOT MT
  16. 16. Insert Heritage Picture CMAJ 2007: 176(8): 1097 Q.E.D
  17. 17. And enjoy the gap
  18. 18. Many thx Now please disagree @docpgb