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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?
Lactate in Critical Care: Mind the Gap!
Look at the mirror…..
If you post a picture on the internet…..
WEAR CLOTHES when taking the picture!
Lactate in Critical Care: Mind the Gap!
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)
Lactate in Critical Care: Mind the Gap!
EG NOT MT
Insert Heritage Picture
CMAJ 2007: 176(8): 1097
Q.E.D
Lactate in Critical Care: Mind the Gap!
And enjoy the gap
Many thx
Now please disagree
brindley@ualberta.ca
@docpgb

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Lactate in Critical Care: Mind the Gap!

  • 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 brindley@ualberta.ca/@docpgb
  • 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. Our sensitive friend, Lactate ” Impending collapse Vulnerable patient Early warning Sensitive Cheap Immediate
  • 4. • Pt intubted in ED d/t decr’d loc • Sick (& pH<7) but not “lactate >40” sick Case 1: Lactate >40 (x3)
  • 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. “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. “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. 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. – “Lactate gap” can be used for good! – Important given •Denial; strange ODs •Late presentations; Consequences of delay – & YOU NEED TWO ANALYZERS
  • 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?
  • 12. Look at the mirror….. If you post a picture on the internet….. WEAR CLOTHES when taking the picture!
  • 14. No such thing as personal opinion… David Brindley PhD, DSc, FRS etc etc
  • 16. 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)
  • 19. Insert Heritage Picture CMAJ 2007: 176(8): 1097 Q.E.D
  • 22. Many thx Now please disagree brindley@ualberta.ca @docpgb