Consult for micu patient with high lactate

[europeman]

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As a surgeon I'm always happy to consult for the micu patient with a crazy high lactate for the concern of dying gut. I always prefer to be called earlier than later.

In the absence of an exam (ie sedated or too sick or whatever), obvious abdominal exam findings (or even with some distended or tender findings say) and no blood in vault.... What's your standard workup?

I basically look at old images... If hasn't had scan in a while and can tolerate contrast a cta of belly shows me vascular stuff.... Which is nice to know but doesn't change my acute management. Basically if the patient doesn't get better with resuscitation I stick a scope in or if too sick I just do bedside laparotomy to see if stuff dead.

Your practice?

Anyone scope? If so why?

 

[europeman]

Bump!!! C'mon peeps!!! 🙂

 

[ACSurgeon]

honestly, if the patient is ill with multi organ system failure (ventilated, on pressers, CRRT, etc) and then develop a lactic acidosis as their 4th or 5th organ system failing(GI), their mortality is pretty close to 100% regardless of anything you do, so we often do nothing.

In a less ill person, what you suggested is reasonable - start with imaging and consider exploring if stable enough. Not sure I'll even do a bedside laparotomy in the ICU. Seems futile...

 

[SLUser11]

Often when patients develop dead gut due to some other underlying issue, they need comfort care rather than one final big whack prior to their inevitable death. What you are describing is basically a diagnostic bedside laparotomy, which isn’t always necessary.


On the other hand, if you believe there is a reversible process happening in their abdomen, resuscitation followed by CT is appropriate. The CT would be to identify something you can’t fix. It is also reasonable to simply take someone directly to the OR for laparoscopy or laparotomy, but honestly it doesn’t happen that often in my practice.


I hope that answers your question.