Are diabetics immunocompromised in your practice?

[wareagle726]

Had some pushback last night from a hospitalist. Been out 4 years and never heard this argument before. 50's male with HTN, IDDM. Came in febrile to 102, obviously tacky. WBC 16k, lactic 2.5. Viral panel neg. Pneumonia on CT. Did all the sepsis stuff and covered with abx. The hospitalist argues with me and says they are stable and can be sent home and when I said they are immunocompromised with DM he said "almost everyone is diabetic so what" Threw me for a loop. I would never consider sending that person home so maybe I had way too conservative training but wanted yalls thoughts.

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[RustedFox]

He's not wrong. About several things.
But I would admit this patient.
Throw in a PORT score and the mouthbreather will shut up and take the admission.

 

[WhatJobDoIPick]

This hospitalist is a *****. Have them come down to the ED and write a note saying this.

 

[Emapp20177]

Severe sepsis. Admit. Done.

Never trust a diabetic.

Hospitalist can come write a note and discharge the patient if they would like to.

 

[southerndoc]

Diabetes doesn't necessarily mean immunocompromised.

However, a lactate of 2.5 concerns me. Even with a low class PSI, patient still needs to be admitted as they meet criteria for severe sepsis.

"You want them to go home? Sure, come discharge them. You're free to put in the order. EMTALA invoked, you have 30 minutes to evaluate the patient. Bu-bye."

 

[BoardingDoc]

Did the patient also have poorly controlled DM with a high glucose (idk, 300+?) If not, I don't really agree with the statement that the patient is immunocompromised as they likely aren't. That said, the potential to get worse is obviously much higher in a patient with DM, and this is clearly an easy admit with the fever, tachycardia and WBC of 16+ with a source.

TL;DR: Semantic disagreement with your comment. Clinical care disagreement with the hospitalist.

 

[InternistDO]

As an internist I consider high dose IDDM or uncontrolled T2DM at least slightly immunocompromised. Someone with an A1c of 6.4 on 500 of metformin probably not, same with a well controlled T1DM.

Is this a patient probably going to be fine if DCed? Sure. But they’re reasonably high risk for decompensation and also at risk for DKA so I would consider it a reasonable admission, especially if they needed fluids. Worst case they feel better in the AM and can get DCed then.

 

[Tiger26]

It sounds like the patient may have looked I'll but I am not considering all diabetics to be immunocompromised. Also, are we really getting concerned about a lactate of 2.5?

Maybe I don't admit enough people?

 

[wareagle726]

This is great geedback and kind of what I was. Looking for. Seems like I’m maybe overly concerned about diabetics being “immunocompromised” based on some of my training. That being said, this patient didnt look well by any means so that is a different story all together lol

 

[Rekt]

It sounds like the patient may have looked I'll but I am not considering all diabetics to be immunocompromised. Also, are we really getting concerned about a lactate of 2.5?

Maybe I don't admit enough people?

No. I see lactates like this all day. Zero concern over something like this. Obviously depends on clinical scenario. I disagree that a diabetic patient is automatically immunocompromised. I’d probably send this patient home based on the limited info.

 

[RustedFox]

To the group:

This has always struck me as weird, too - but it's worth a mention.
I can remember (and I'm sure that I'm correct) various textbooks mentioning uncontrolled DM as a risk factor for immunocompromise.
Specifically, they cited direct leukocyte dysfunction in the hyperglycemic milieu as the concern.

However, this word "immunocompromised" means different things in different settings.
We're EM, so we hear this word, and we think "true neutropenia", "transplant-rejection drugs", or [whatever].
We don't see Bill McWaistline on metformin/glyburide and think "immunocompromised !!"

This patient sounds old, tachy, and sick. Admit. Do your job, hospitalist.

That being said, I interpret the cavalier dismissal of the hospitalist in this vignette like this: "tru, bro".
Because your average American really is a fat, disgusting, powdered-sugary, chocolate-syrupy mess.
He's no longer fazed at all. Nor should he be.
What's our national obesity rate up to now? Like 42 percent or something?



Pathetic. Get fit.
Millions must lift.

 

[Emapp20177]

This is great geedback and kind of what I was. Looking for. Seems like I’m maybe overly concerned about diabetics being “immunocompromised” based on some of my training. That being said, this patient didnt look well by any means so that is a different story all together lol

Keep your practice setting in mind. Persistently tachycardic despite fluids, elevated lactate that doesn't resolve with fluids, or ill appearing diabetic with systemic bacterial infection gets admitted by me every time. But I work in a state that I worry about malpractice. And I've seen too many ugly bouncebacks with cases similar to what you are describing.

Again, the hospitalist can evaluate and decide what they want to do.

 

[thegenius]

I think diabetics have a harder time fighting infection, but for a different physiologic reason than someone who has AIDS or taking chemotherapy drugs. I think it has more to do with how high their sugars are. Although I've briefly looked into it just now and apparently it's quite complicated ("Numerous studies have been conducted to determine the diabetes-related mechanisms that impair the host’s defense against pathogens. These mechanisms include suppression of cytokine production, defects in phagocytosis, dysfunction of immune cells, and failure to kill microbials." - Type 2 Diabetes and its Impact on the Immune System)

I think if all of your vitals signs normalized and lactate normalized with ED care, and assuming the patient is somewhat trustworthy, he could go home.

Lastly, if you think the pt should be admitted and hospitalist says no, then simply ask them to see the patient and write a consult note.

 

[Splenda88]

This is an automatically admit at my shop and even the most difficult hospitalists here would not contest it

What was the patient BP?

How did he/she do after he/she got fluid and abx?

Why did you get a CT on that patient?

 

[JacobMcCandles]

This could go either way. If they’re an uncontrolled diabetic then it’s an easy admit. If it’s under good control and they respond to treatment, satting well, and want to go home then that’s likely reasonable. On the flip side, there are a ton of other admits for a hospitalist to whine over but this would be a pretty easy admit to defend.

 

[thegenius]

No. I see lactates like this all day. Zero concern over something like this. Obviously depends on clinical scenario. I disagree that a diabetic patient is automatically immunocompromised. I’d probably send this patient home based on the limited info.

I agree, 2.5 is nothing.
Hell, 1/3 of the patients yell and scream prior to the lab draw, which is enough to elevate your lactate

 

[emergentmd]

To me, admission all depends on how they look. If you did a CT to see pneumonia, then likely the CXR didn't show much.

Nothing on the history screams admission. lactate/wbc doesn't scare me.

Tachy and how they look matters. if they are 105 Tachy and looks good, they go home. If they look bad no matter what, they get admitted. if they are tachy above 120 and I can't get it down, then likely admit.

I treat the pt and not the numbers.

 

[bky3c]

Had some pushback last night from a hospitalist. Been out 4 years and never heard this argument before. 50's male with HTN, IDDM. Came in febrile to 102, obviously tacky. WBC 16k, lactic 2.5. Viral panel neg. Pneumonia on CT. Did all the sepsis stuff and covered with abx. The hospitalist argues with me and says they are stable and can be sent home and when I said they are immunocompromised with DM he said "almost everyone is diabetic so what" Threw me for a loop. I would never consider sending that person home so maybe I had way too conservative training but wanted yalls thoughts.

That is the most ridiculous logic. Using that logic... since it's so common for someone to go to the ED with chest pain, we should turn them all away? I mean, everyone has it, so what's the big deal? (Never mind the fact that diabetes and heart disease are two of the top ten causes of death for Americans per the CDC.)

 

[southerndoc]

I agree, 2.5 is nothing.
Hell, 1/3 of the patients yell and scream prior to the lab draw, which is enough to elevate your lactate

2.5 with an infection is severe sepsis. Discharging that is asking to be sued. 2.5 in someone with alcohol intoxication, seizure, getting nebulizer treatments, etc. is a different story. That's defensible. Discharge a few more septic patients with lactates >2 and I may try to be retained to be your expert witness to try to defend you (which I cannot).

 

[Janders]

2.5 with an infection is severe sepsis. Discharging that is asking to be sued. 2.5 in someone with alcohol intoxication, seizure, getting nebulizer treatments, etc. is a different story. That's defensible. Discharge a few more septic patients with lactates >2 and I may try to be retained to be your expert witness to try to defend you (which I cannot).

A bridge too far imho.

Lactate prediction for sepsis is so-so and the precise cutoff where things get “bad” is quite debatable. Especially on initial draw (6h draw better). Lactates in the 2s may be red flags but they aren’t required admissions. I would absolutely defend that as an expert.

if I tried to admit every infection with a lactate of 2-2.5…

 

[CoolDoc1729]

Diabetes doesn't necessarily mean immunocompromised.

However, a lactate of 2.5 concerns me. Even with a low class PSI, patient still needs to be admitted as they meet criteria for severe sepsis.

"You want them to go home? Sure, come discharge them. You're free to put in the order. EMTALA invoked, you have 30 minutes to evaluate the patient. Bu-bye."

One day I asked the hospitalist why he doesn’t just dc a patient my colleague admitted, instead of waiting until she leaves and complaining to me that she admits everyone (which is true tbh)

“I don’t want the liability”

It’s like well neither do we …

 

[southerndoc]

A bridge too far imho.

Lactate prediction for sepsis is so-so and the precise cutoff where things get “bad” is quite debatable. Especially on initial draw (6h draw better). Lactates in the 2s may be red flags but they aren’t required admissions. I would absolutely defend that as an expert.

if I tried to admit every infection with a lactate of 2-2.5…

You might take their money to defend it, but it's not going to be a successful defense.

 

[Janders]

You might take their money to defend it, but it's not going to be a successful defense.

So all infections with lactate of 2.5 must be admitted?
Must we all get delta lactates to show the repeat is 1.9?
(For clarity I’m not trying to be a jerk, genuinely curious tone here. Just wondering where is is standard of care. It’s absolutely novel to me.)

Assuming the rest of the care is usual and standard is absolutely defend that single data point.

 

[southerndoc]

So all infections with lactate of 2.5 must be admitted?
Must we all get delta lactates to show the repeat is 1.9?
(For clarity I’m not trying to be a jerk, genuinely curious tone here. Just wondering where is is standard of care. It’s absolutely novel to me.)

Assuming the rest of the care is usual and standard is absolutely defend that single data point.

Wait, you said you were willing to defend as an expert witness but you don't know standard of care?

Standard of care is lactate >2 with infection/2 SIRS qualifies as severe sepsis. Severe sepsis being discharged can not only be painted by the plaintiff's counsel as below standard of care, but can also be argued as grossly negligent. Sure, a lot of these patients might do ok going home. The one who doesn't and sues is going to burn your behind majorly. The plaintiff will even argue that CMS has established SEP-1 criteria to define severe sepsis.

 

[Janders]

Wait, you said you were willing to defend as an expert witness but you don't know standard of care?

Standard of care is lactate >2 with infection/2 SIRS qualifies as severe sepsis. Severe sepsis being discharged can not only be painted by the plaintiff's counsel as below standard of care, but can also be argued as grossly negligent. Sure, a lot of these patients might do ok going home. The one who doesn't and sues is going to burn your behind majorly. The plaintiff will even argue that CMS has established SEP-1 criteria to define severe sepsis.

Oh I did say I’m willing to defend it as an expert, but I remain curious if anyone else feels their local standard of care is to admit all infection with initial lactate of 2.5.

Remember in the sepsis 3 definition there is no severe sepsis. There is no lactate screening. They note a lactate of > 2 AFTER adequate fluid resus AND ongoing hypotension requiring vasopresors defines septic shock.

SEP-1 is a bundle intended to improve quality of care of patients admitted with sepsis / septic shock. It is not intended to define the standard of care for outpatients discharged from the ED, and CMS does not construe it in that way. To argue that an isolated lactate of 2.5 (or 2.1) which hits “severe sepsis” for Sep-1 requires uniform hospital admission is grossly twisting the intent of metric, and also not at all supported by the underlying science. All infections with Cr 2 or plt 149 require admission by this logic. Clearly these are red flags a physician should consider and address, but assuming that was done…

 

[southerndoc]

Oh I did say I’m willing to defend it as an expert, but I remain curious if anyone else feels their local standard of care is to admit all infection with initial lactate of 2.5.

Remember in the sepsis 3 definition there is no severe sepsis. There is no lactate screening. They note a lactate of > 2 AFTER adequate fluid resus AND ongoing hypotension requiring vasopresors defines septic shock.

SEP-1 is a bundle intended to improve quality of care of patients admitted with sepsis / septic shock. It is not intended to define the standard of care for outpatients discharged from the ED, and CMS does not construe it in that way. To argue that an isolated lactate of 2.5 (or 2.1) which hits “severe sepsis” for Sep-1 requires uniform hospital admission is grossly twisting the intent of metric, and also not at all supported by the underlying science. All infections with Cr 2 or plt 149 require admission by this logic. Clearly these are red flags a physician should consider and address, but assuming that was done…

You win

 

[Janders]

You win

That’ll be $500/hr minimum 4hr thank you

 

[Tiger26]

If this person looks sick and didn't turn around in the ED, I'd probably admit them. That said, I bet 9/10 of these look way better after fluids and are discharged home, especially if breathing comfortably and saturating well.

I'm a little surprised about the lactate controversy. For some of the above posters, I could see someone like Peter Rosen attacking a physician for not automatically admitting someone with a lactate of 2.5 (and then getting censured), but most of them are going home in our practice. Given the bioavailability of oral vs IV antibiotics, what benefit does hospital admission provide unless something else is necessary that is only available in the hospital?

We use a lactate of 4 as our cutoff for "sepsis." That said, what does sepsis even mean anymore when everyone with a cold is "septic."

 

[thegenius]

2.5 with an infection is severe sepsis. Discharging that is asking to be sued. 2.5 in someone with alcohol intoxication, seizure, getting nebulizer treatments, etc. is a different story. That's defensible. Discharge a few more septic patients with lactates >2 and I may try to be retained to be your expert witness to try to defend you (which I cannot).

Will not argue a definition. Will suggest that "severe sepsis" often, almost 100% of the time, resolves with standard of care interventions like antibiotics and fluids. and the resolution can happen quickly too, while in the ED.

 

[thegenius]

So all infections with lactate of 2.5 must be admitted?
Must we all get delta lactates to show the repeat is 1.9?
(For clarity I’m not trying to be a jerk, genuinely curious tone here. Just wondering where is is standard of care. It’s absolutely novel to me.)

Assuming the rest of the care is usual and standard is absolutely defend that single data point.

It's obvious by this very thread that standard of care is not concrete and based on numbers. It's individualized and there is some nuance. This is opposite of more conrete medical emergencies like acute neurologic change (stroke), STEMI, acute dissection, etc. That's why so many of us don't like the severe sepsis guidelines. Young people with routine strep pharyngitis often have severe sepsis (if we get a lactate) and none of us would admit routine strep pharyngitis.

I'm a little surprised by those that say severe sepsis is auto-admit.

 

[thegenius]

Wait, you said you were willing to defend as an expert witness but you don't know standard of care?

Standard of care is lactate >2 with infection/2 SIRS qualifies as severe sepsis. Severe sepsis being discharged can not only be painted by the plaintiff's counsel as below standard of care, but can also be argued as grossly negligent. Sure, a lot of these patients might do ok going home. The one who doesn't and sues is going to burn your behind majorly. The plaintiff will even argue that CMS has established SEP-1 criteria to define severe sepsis.

To be specific, that is a definition, not standard of care. If it were standard of care to admit severe sepsis, then the guidelines could easily say "admit" to the hospital, along with getting source control, early antibiotics, IV fluids, and BP management.

 

[JacobMcCandles]

This is where common sense comes into play. A person with sepsis and a lactic acid of 2.0 that is well appearing can go home but a patient with sepsis and a lactic acid of 2.1 but still well appearing needs to be admitted because it's severe sepsis is ridiculous. Hopefully nobody here is trying to claim malpractice in these situations.

 

[wareagle726]

This is all amazing feedback and the discussion I was trying to get. Like I said, this person didnt look “well”, didnt have good followup, i was at a freestanding so the hospitalist couldn’t come see them, and my gestalt was to put then in the hospital…I’ve admitted people for less. Also the lactic was the least of my concern.

 

[Mount Asclepius]

I think your issue possibly relates more to on how to convey the admission/transfer adequately rather than diabetes being a big factor or the numbers.

You were appropriately concerned by a middle aged, diabetic, ill-appearing patient with pneumonia and associated fever, tachycardia, leukocytosis and lactic acidosis with poor follow-up in a resource deficient environment. Many patients even in this demographic could be managed as outpatients if no hypoxia, no septic shock, and no other acute comorbid conditions such as AKI, uncontrolled hyperglycemia, etc.

The skill is in how you quickly summarize the patient over the phone. If done correctly, I’d be surprised by any pushback unless other factors at play such as an overworked hospitalist, high patient loads with boarding, or financial considerations such as insurance status affecting transfer.

 

[RustedFox]

If this person looks sick and didn't turn around in the ED, I'd probably admit them. That said, I bet 9/10 of these look way better after fluids and are discharged home, especially if breathing comfortably and saturating well.

I'm a little surprised about the lactate controversy. For some of the above posters, I could see someone like Peter Rosen attacking a physician for not automatically admitting someone with a lactate of 2.5 (and then getting censured), but most of them are going home in our practice. Given the bioavailability of oral vs IV antibiotics, what benefit does hospital admission provide unless something else is necessary that is only available in the hospital?

We use a lactate of 4 as our cutoff for "sepsis." That said, what does sepsis even mean anymore when everyone with a cold is "septic."

My lactate is 2.6 after eating Mexican food.
Nothing means anything anymore.

 

[Splenda88]

Good to see that EM is like IM.

I remember we use to spend 30+ minutes in residency discussing trivial things such as hyponatremia of 133 or trop 0.05

 

[thegenius]

My lactate is 2.6 after eating Mexican food.
Nothing means anything anymore.

Now I'm going to admit you, you little b*tch and don't complain. You're getting zosyn, fluids, and please STFU. And stop f*cking around PLA-EEZE!

And why does your tox screen have fentanyl, meth, cocaine and benzos? WTF? NURSE!!!!! GIVE MORE FLUIDS!!!!!!! NNUUURRSSEEEE!!!!!!

 

[RustedFox]

"Johnny Mnemonic" (1995)

 

[Siggy]

Oh I did say I’m willing to defend it as an expert, but I remain curious if anyone else feels their local standard of care is to admit all infection with initial lactate of 2.5.

Remember in the sepsis 3 definition there is no severe sepsis. There is no lactate screening. They note a lactate of > 2 AFTER adequate fluid resus AND ongoing hypotension requiring vasopresors defines septic shock.

SEP-1 is a bundle intended to improve quality of care of patients admitted with sepsis / septic shock. It is not intended to define the standard of care for outpatients discharged from the ED, and CMS does not construe it in that way. To argue that an isolated lactate of 2.5 (or 2.1) which hits “severe sepsis” for Sep-1 requires uniform hospital admission is grossly twisting the intent of metric, and also not at all supported by the underlying science. All infections with Cr 2 or plt 149 require admission by this logic. Clearly these are red flags a physician should consider and address, but assuming that was done…

SEP 1 is the standard of care because of the golden rule.

What's the "golden rule?" He (CMS) who has the gold makes the rules.

Lactate is accepted as a potential measure of malperfusion, unless you can document another cause for the lactic acidosis. Sepsis 3 didn't really drop the "severe sepsis" definition of Sep-1 It dropped the "sepsis" aspect and renamed "severe sepsis" as "sepsis." It moved the goal poles in a rather appropriate way. However that means that the concept of severe sepsis (over reacting immune system resulting in end organ damage) didn't go away. I think it's going to be very hard to defend a bad outcome with a discharge from a patient with a known high lactate that's either directly attributed to infection or not attributed to anything. Additionally if you're using the SEP-3 standard, are you calculating a SOFA score, or are you mixing and matching with SIRS criteria to determine sepsis (SEP-1), and then using SEP-3 to justify ignoring a lactic acid?


My hospital isn't the best. If the hospitalist or ED called me up and said, "Hey, we have a weak sepsis admit with an elevated lactic acid," I'd be hard pressed to say no to at least a night in stepdown.

If someone has a Cr of 2 and no known history of CKD where you're going to document "sepsis" and "AKI," it becomes hard to justify a discharge.

I agree that an isolated lactic acid arguably doesn't mean much. An isolated troponin doesn't mean much either. However are you going to send home a patient with sharp, reproducible chest pain, but a reasonably elevated trop (say, high sensitivity trop of 100 or a regular trop of 1) without at least a delta trop or attributing the trop to a non-ACS cause (i.e. known CKD patient where the trop is always elevated and this trop is near baseline)? At least a delta-lactate that's down trending gives the defense something to work with.

 

[Siggy]

I may try to be retained to be your expert witness to try to defend you (which I cannot).

As an aside... are the SEAK courses worth it to start expert witness work?

 

[Janders]

SEP 1 is the standard of care because of the golden rule.

What's the "golden rule?" He (CMS) who has the gold makes the rules.

Lactate is accepted as a potential measure of malperfusion, unless you can document another cause for the lactic acidosis. Sepsis 3 didn't really drop the "severe sepsis" definition of Sep-1 It dropped the "sepsis" aspect and renamed "severe sepsis" as "sepsis." It moved the goal poles in a rather appropriate way. However that means that the concept of severe sepsis (over reacting immune system resulting in end organ damage) didn't go away. I think it's going to be very hard to defend a bad outcome with a discharge from a patient with a known high lactate that's either directly attributed to infection or not attributed to anything. Additionally if you're using the SEP-3 standard, are you calculating a SOFA score, or are you mixing and matching with SIRS criteria to determine sepsis (SEP-1), and then using SEP-3 to justify ignoring a lactic acid?


My hospital isn't the best. If the hospitalist or ED called me up and said, "Hey, we have a weak sepsis admit with an elevated lactic acid," I'd be hard pressed to say no to at least a night in stepdown.

If someone has a Cr of 2 and no known history of CKD where you're going to document "sepsis" and "AKI," it becomes hard to justify a discharge.

I agree that an isolated lactic acid arguably doesn't mean much. An isolated troponin doesn't mean much either. However are you going to send home a patient with sharp, reproducible chest pain, but a reasonably elevated trop (say, high sensitivity trop of 100 or a regular trop of 1) without at least a delta trop or attributing the trop to a non-ACS cause (i.e. known CKD patient where the trop is always elevated and this trop is near baseline)? At least a delta-lactate that's down trending gives the defense something to work with.

So we should not discharge isolated lactates of 2.1 and should, at minimum, hold in the ED for serial rechecks?

 

[BoardingDoc]

View attachment 384155

"Johnny Mnemonic" (1995)

Aww man. Love that movie. Particularly love his rant towards the end while standing in a junkyard screaming that he wants room service and a "$10000 a night hooker"

 

[RustedFox]

Aww man. Love that movie. Particularly love his rant towards the end while standing in a junkyard screaming that he wants room service and a "$10000 a night hooker"

I do, too - and it's generally panned by critics and the public alike.
More prescient is Henry Rollins' rant about how technology is the cause of the "black shakes" disease

 

[Siggy]

So we should not discharge isolated lactates of 2.1 and should, at minimum, hold in the ED for serial rechecks?

What’s the overall context?

It’s like troponins. How high is too high depends on context.

 

[BoardingDoc]

What’s the overall context?

It’s like troponins. How high is too high depends on context.

So the answer to @Janders question is no then. If the answer is "context matters" it can't also be that "lactate must be shown to be downtrending prior to DC."

That's certainly the page I'm on anyway. A healthy 35 year old with pneumonia, normal vitals but a wbc of 14 and a lactate of 2.1 can go home with oral ABX in my book.

The sick looking 68 year old diabetic wheelchair bound patient with cellulitis and the same labs and vitals can't.

 

[RustedFox]

Aww man. Love that movie. Particularly love his rant towards the end while standing in a junkyard screaming that he wants room service and a "$10000 a night hooker"

Additional thought: that rant demanding room service and a 10k/night hooker reminds me eerily of so many of my patients; demanding things that are in no way available in the setting.

 

[emergentmd]

Maybe I am an older doc and the newly minted ones are now trained differently.

I treat pts and not numbers. If Op said pt did not look well, then just admit so you can sleep well at night. He might do well going home, but if it worries you enough, admit. Last thing you want to hear coming back the next day and getting the dreaded, "Do you remember the febrile pt you sent home yesterday......"

I don't remember ever ordering a lactic acid level unless I am going to admit b/c thats what some hospitalist want. If they look good, I am not ordering a lactate that puts me in a corner.

Just like if someone I know doesn't have a PE, I am not ordering a Ddimer that puts me in a corner.

 

[Rendar5]

Agreed for the most part, except the entire point of checking lactics is to look for occult septic shock. That is, finding someone who looks good but is going to crump. Somewhere along the way it got waylayed by equivocal lactics between 2 and 4.

It’s like BNP. Designed to create a divide at the extremes to assist in decision making, not to use equivocal middling results to determine treatment.

Lactics were designed to be performed on people who look decent.

 

[CoolDoc1729]

Maybe I am an older doc and the newly minted ones are now trained differently.

I treat pts and not numbers. If Op said pt did not look well, then just admit so you can sleep well at night. He might do well going home, but if it worries you enough, admit. Last thing you want to hear coming back the next day and getting the dreaded, "Do you remember the febrile pt you sent home yesterday......"

I don't remember ever ordering a lactic acid level unless I am going to admit b/c thats what some hospitalist want. If they look good, I am not ordering a lactate that puts me in a corner.

Just like if someone I know doesn't have a PE, I am not ordering a Ddimer that puts me in a corner.

On the topic of being backed into a corner.

Yesterday I was seeing a patient at triage who had 6-hour history of swelling under his jaw, seemed to me on exam it must be a swollen submandibular gland. He’s 75 and some CNA friend told him it must be either cancer or an abscess (?!) so I decided to order a CT to be sure he just needs to go eat lemon drops.

I leave the triage room for ten seconds to put in an IV, a POC Chem and a CT ST Neck. When I return to the room, to my horror, the triage nurse is doing an ekg.

Inside I was screaming, but in a calm voice I asked, why are you doing an ekg ?

The patient, whose doctor died 18 months ago so he doesn’t have a pcp, had BP 190/105. So the nurse decided an ekg was needed.

I watched in horror as AF RVR with diffuse ST depressions comes across the screen.

Having been backed into the cardiac corner, I ordered cardiac workup. HS Trop of 60. Well now I’m way in the corner. Meanwhile the CT ST neck showed of course the swollen submandibular gland. He has no chest pain, dizziness, dyspnea, palpitations, nothing. He clearly lives in this condition.

So I went to tell him we should admit him for the nstemi and new onset AFRVR. Terrible follow up in my town, he’d be lucky to see cards within a month. He looked at me like I was out of my mind and said I’m going home!

Sometimes the right answer for these borderline folks is to just ask what they are comfortable with, and document carefully. If someone has pneumonia and a lactic of 2.5, I will neither force them to stay nor shove them out the door. I don’t know far off their baseline most people are and what support/resources they may have at home. A diabetic whose sugar is always between 80 and 160 is not the same as a diabetic whose sugar is always HI.

 

[Janders]

Agreed for the most part, except the entire point of checking lactics is to look for occult septic shock. That is, finding someone who looks good but is going to crump. Somewhere along the way it got waylayed by equivocal lactics between 2 and 4.

It’s like BNP. Designed to create a divide at the extremes to assist in decision making, not to use equivocal middling results to determine treatment.

Lactics were designed to be performed on people who look decent.

Exactly. Lactate of 4 is (!!) lactate of 3 gets a raised eyebrow. Lactate of 2.1… it’s like a wbc of 15k. I consider it, but I’ve never considered it to primarily drive management or decision making.