I could write posts all day about this new Jenny mcjennyson we have working nights. The question I get that are so outside my realm. I think she is deathly afraid to call her attending
Would The white cell lysis show up on the labs? I honestly don’t know. That is why I recommended a uric acid level and calling someone who knows more than me. I admit I may have just been lucky.
Lol, not sure if you’re joking or not, but he’s referring to rasburicase which is one of those classic learn for the boards and forget medication because you will probably never use it in reality.
And the snozzberries taste like snozzberries!
I’m sure they’re super pleasant when extubated lol. What percent of them walk out AMA shortly after being extubated, I wonder…
Yea man it totally does
I sit on these patients all the time, it’s rare that they don’t start showing signs of life after 3-4 hours. Saves an ICU bed.
Do you know how they ended up doing? I thought that the whole thing with rasburicase was to give it to prevent AKI in the setting of hyperuricemia/TLS.
Ya, it's called pseudohyperkalemia, you can see it in CLL where the cells are fragile and in the act of drawing blood you lyse them. My first time seeing it was on a newly diagnosed CLL where the K was >10 and he relatively fine with no EKG changes.
You can see it in ALL as well. My single experience it wasn't the lab draws that was lysing the RBC but the tubing to the lab and spinning them. Kid had a K of 12 with a normal EKG and the istat showed K of 3. For 3 days we had to run an istat everytime we sent lytes to the lab to keep everyone from freaking out.
It was very strange, our lab claimed they couldn't run a whole blood potassium - ie without spinning the tube.
I’ve seen the same thing after giving intralipid, only POC labs are accurate.
You beat my personal record low Hgb of 1.9, which also looked like red Kool-Aid.
My personal record is "Doc, we don't have enough cells in the sample to give an accurate Hgb." 34 yo minimally responsive, pale as a ghost, dropped off by friends who mention something about hematemesis and take off. No other hx provided. He's hypotensive, HR of 150, RR of 50. Blood looks like just serum w/ a single drop of food coloring. Abdomen is swollen. His hgb was 2.0 after 4 units of pRBCs. I kept that guy alive for 10 hours, stayed 3 hrs after my shift. Mass transfusion protocol, 20 u pRBCs, 10u Plts, 10u FFP. Blakemore tube. GI won't scope. IR won't touch the pt because he is too unstable and INR is >10. His lactic acid was 45. His pH was 6.7. I waited about 2 hrs before intubating him because I felt that intubation would be an immediate death sentence, as there was no way I could match his minute ventilation on the vent, but he eventually started looking a bit better after about 10u pRBCs, so I figured that was my time to intubate. Put him at a RR of 36 on the vent, with a tidal volume of 800 (he was a small guy), just to try to somewhat match his MV. Initial NG tube placed puts out 2L of blood from his stomach. Blakemore tube then placed, but not much improvement. ICU admitted him. Blood bank eventually ran out of blood to release. The patient died a few hours later.
That's a crazy case, and I'm going to take this in a slightly controversial direction. With the labs you're describing and the general clinical course, I don't know if this was "heroic measures" or "waste of resources."
That was my thought afterwards, and if we are talking about the greater good, you are probably right, but I would do it again even for a slight chance of saving a 34 year old.
Did you ever follow up and figure out what the original etiology was? Alcoholic cirrhosis, or other liver pathology? I feel like 34 is pretty young to get full on cirrhosis and esophageal varices. But this may be the ignorant med student in me talking...
Fair question and 34 is fairly young. In the ICU during residency I pronounced a 23 year old with alcoholic cirrhosis and end stage liver disease after she and family elected for comfort care. She reportedly drank around a handle a day and started drinking at age 13.
I'm speechless.
My call to my intensivist buddy was simply: “34 yo GI bleed, sickest patient I have ever seen that is still technically alive, please come help.”
Holy cow man, how much does one have to drink to get to this point?
Roughly 1+ Liters of hard alcohol daily is where I've seen this. I don't see a ton of drug use in my neck of the woods. Occasional fent ODs. No meth to speak of. TONS of alcoholism though. I also trained somewhere where we saw a LOT of liver patients so the idea of a 30 yr old cirrhotic with varices is unfortunately not surprising.
Another classic case of interventionalists who refuse to do their job. “He’s too unstable to give him the treatment that will stop him from being unstable.”
Dude. That guy is dead. Even if by some miracle the guy doesn’t die (and it would be a miracle), he has stroked out. He is already infarction several organs.
You can't stop bleeding like that with a scope. Patient won't survive IR procedure. There's nothing to be done for patients like that except have ICU talk about palliation and withdrawal of active treatment after a certain point.
Not strange.
There has to be a huge genetic component too- I’ve also seen many people who drink that much and are 65 before it gives them any trouble … sad when they’re in their 30s +/- small kids at home.
