When to Check a Lipase?

[The Knife & Gun Club]

So I had a case recently which has me a little puzzled.

EMS brings in a dude from local homeless shelter in respiratory distress - has a history of COPD + CHF, they’ve got him on cpap and his vitals are OK, low grade fever, but clearly sick. Mentating fine, no abdominal complaints.

Did the usual stuff in the ED, abx, steroids, careful IVF because of the CHF...labs (including liver stuff) only remarkable for metabolic acidosis and a white count. Notably did not get a lipase. Admitted to ICU, where he promptly decompensates, peri-intubation arrest, ROSC, ends up on 3 pressors, AKI —> renal necrosis, and then finally fulminant liver failure over the course of 72 hours. They never found a source infection.

Somewhere in there someone gets a lipase that came back >4000, and liver ultrasound also happened to see some large gallstones, but no evidence of an obstructing stone or CBD dilation.

Dude dies about 5 days after admission.

ICU attending puts in their final note, that they believe the patient had gallstone pancreatitis causing ARDS missed by the EP because we didn’t get lipase in the ED. I’m biased but feel like the bumped lipase was probably more from multi organ failure/persistent hypotension/pressors.

So my question is...are y’all consistently checking lipases on sick non-abdominal complaints?

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[NITRAS]

Yall must have a great relationship with the ICU docs.

 

[dadaddadaBATMAN]

So I had a case recently which has me a little puzzled.

EMS brings in a dude from local homeless shelter in respiratory distress - has a history of COPD + CHF, they’ve got him on cpap and his vitals are OK, low grade fever, but clearly sick. Mentating fine, no abdominal complaints.

Did the usual stuff in the ED, abx, steroids, careful IVF because of the CHF...labs (including liver stuff) only remarkable for metabolic acidosis and a white count. Notably did not get a lipase. Admitted to ICU, where he promptly decompensates, peri-intubation arrest, ROSC, ends up on 3 pressors, AKI —> renal necrosis, and then finally fulminant liver failure over the course of 72 hours. They never found a source infection.

Somewhere in there someone gets a lipase that came back >4000, and liver ultrasound also happened to see some large gallstones, but no evidence of an obstructing stone or CBD dilation.

Dude dies about 5 days after admission.

ICU attending puts in their final note, that they believe the patient had gallstone pancreatitis causing ARDS missed by the EP because we didn’t get lipase in the ED. I’m biased but feel like the bumped lipase was probably more from multi organ failure/persistent hypotension/pressors.

So my question is...are y’all consistently checking lipases on sick non-abdominal complaints?

Oh yeah, I forgot lipase and ultrasound were limited to ed use in most hospitals.

I’m trying to imagine writing a note that said “I can’t diagnose something in 5 days of repeated assessment that an ed doc can diagnose in less than 5 hours.”

On the one hand, obviously bull**** and I agree with the snark about your relationship with icu.

On the other hand, what a “compliment” from our esteemed colleagues


Edit: also in answer to your question I would probably not get a lipase on this patient. It is a good reminder that the pancreas can cause ards though, which is something that your medicine/fellowship trained colleagues could have pontificated on over the course of 5 days

 

[WilcoWorld]

So I had a case recently which has me a little puzzled.

EMS brings in a dude from local homeless shelter in respiratory distress - has a history of COPD + CHF, they’ve got him on cpap and his vitals are OK, low grade fever, but clearly sick. Mentating fine, no abdominal complaints.

Did the usual stuff in the ED, abx, steroids, careful IVF because of the CHF...labs (including liver stuff) only remarkable for metabolic acidosis and a white count. Notably did not get a lipase. Admitted to ICU, where he promptly decompensates, peri-intubation arrest, ROSC, ends up on 3 pressors, AKI —> renal necrosis, and then finally fulminant liver failure over the course of 72 hours. They never found a source infection.

Somewhere in there someone gets a lipase that came back >4000, and liver ultrasound also happened to see some large gallstones, but no evidence of an obstructing stone or CBD dilation.

Dude dies about 5 days after admission.

ICU attending puts in their final note, that they believe the patient had gallstone pancreatitis causing ARDS missed by the EP because we didn’t get lipase in the ED. I’m biased but feel like the bumped lipase was probably more from multi organ failure/persistent hypotension/pressors.

So my question is...are y’all consistently checking lipases on sick non-abdominal complaints?

That's a ridiculous thing to put in the chart. Without biliary obstruction, how would this patient be managed any differently? Yes, pancreatitis can cause sepsis, but it sounds like you were treating sepsis. Maybe you could be critiqued that, if you've got a super sick patient don't worry so much about CHF and just effing give the 30cc/kg of fluids - we'll diurese him later, but a lipase in the ED wasn't going to save this guy.

Now, if he had a biliary obstruction an ERCP may have made a difference, but it doesn't sound like they did an ERCP in the 5d b/w ED presentation and death.

 

[door_to_balloon_knot]

Someone come and chime in or else I never want to hear or read again from the specialists or admitting teams “WhY DOeS ED DoKtoR oRdeR EvERytHiNG?!?! HoW duMb!!!@&@&!”

 

[door_to_balloon_knot]

Also fk those guys that try and blame another physician for poor outcomes when the differential is wider than their mother’s arsehole.

 

[Rekt]

Lipase is on our sepsis order set. I typically check in altered patients and critically ill patients.

The icu doc here is a piece of garbage, but I'm also very liberal with my lipase ordering. Sepsis, ards, AMS, almost any abdominal complaint, hx of EtOH, etc.

It's a very simple test that for some reason attendings like to make a fuss/pimp on why you're ordering it sometimes.

Someone come and chime in or else I never want to hear or read again from the specialists or admitting teams “WhY DOeS ED DoKtoR oRdeR EvERytHiNG?!?! HoW duMb!!!@&@&!”

"Omg the ER docs CT everything"

Calling an admission "why didn't you CT x? I want a CT first!"

 

[SpacemanSpifff]

So I had a case recently which has me a little puzzled.

EMS brings in a dude from local homeless shelter in respiratory distress - has a history of COPD + CHF, they’ve got him on cpap and his vitals are OK, low grade fever, but clearly sick. Mentating fine, no abdominal complaints.

Did the usual stuff in the ED, abx, steroids, careful IVF because of the CHF...labs (including liver stuff) only remarkable for metabolic acidosis and a white count. Notably did not get a lipase. Admitted to ICU, where he promptly decompensates, peri-intubation arrest, ROSC, ends up on 3 pressors, AKI —> renal necrosis, and then finally fulminant liver failure over the course of 72 hours. They never found a source infection.

Somewhere in there someone gets a lipase that came back >4000, and liver ultrasound also happened to see some large gallstones, but no evidence of an obstructing stone or CBD dilation.

Dude dies about 5 days after admission.

ICU attending puts in their final note, that they believe the patient had gallstone pancreatitis causing ARDS missed by the EP because we didn’t get lipase in the ED. I’m biased but feel like the bumped lipase was probably more from multi organ failure/persistent hypotension/pressors.

So my question is...are y’all consistently checking lipases on sick non-abdominal complaints?

Tough case that likely would have ended badly regardless of having a lipase early. That's zero chill from the ICU attending. Agree that management would not change unless there was a gallstone implicated - ARDS standards apply regardless. I agree with others that I have a low threshold for a broad diagnostic evaluation in critically ill patients, including a lipase.

Give the 30 cc/kg for a septic patient despite the CHF history. Septic patients with CHF do better when fluid resuscitated.

I don't think you can say with any certainty that septic patients with pre-existing "volume up" states do better - maybe equally well. In the absence of elevated shock index or hypotension, as in this case, I don't know that the SSC standard is warranted. It all depends on the patient in front of you.

 

[dadaddadaBATMAN]

I don’t necessarily disagree. It totally depends on the patient in front of you. I hear all too frequently though that EPs didn’t give fluids just because a patient had a history of CHF or ESRD. Basing solely whether or not to give IVFs on that past medical history is wrong in my opinion. I think we tend to under fluid resuscitate patients in the ED rather than the opposite.

Multicenter Implementation of a Treatment Bundle for Patients with Sepsis and Intermediate Lactate Values

I deleted my initial post related to IVFs, because it is a separate topic from the OPs question. I didn’t want to derail the lipase discussion.

This is ultimately a philosophical debate until we have more data. It’s the whole purpose of that clovers trial

Some say we give too much fluid before pressure and end with higher number of days on the vent, others say we can “shoot first and diurese later.”

I tend to like the pressors because 1. They work, 2. You have less crap you have to do after starting em.

Central lines are pretty easy. Crash intubations and dealing with hypotension on bipap are really annoying.

Liberal Versus Restrictive Intravenous Fluid Therapy for Early Septic Shock: Rationale for a Randomized Trial - PubMed

Prompt intravenous fluid therapy is a fundamental treatment for patients with septic shock. However, the optimal approach for administering intravenous fluid in septic shock resuscitation is unknown. Two competing strategies are emerging: a liberal fluids approach, consisting of a larger volume...

pubmed.ncbi.nlm.nih.gov

 

[gutonc]

My smarta** answer (as an outpatient doc) to the question in the subject line is: "when they hit the floor".

Something tells me this isn't the first time that ICU doc has been a complete d*** and likely not the last.

 

[curbsideconsult]

Just a lowly intern such as yourself (not EM), but I don't think you did anything wrong. ED decisions are: dying/not dying and admit/discharge. You don't have time to go through every single system like, oh, I don't know, ICU does. You have that one person and 30 other potentially very sick patients waiting for you.

Clearly the ICU attending was CYA-ing because THEY didn't get the lipase soon enough. Everyone in medicine knows ICU rounding covers every single system and they should be blaming themselves for missing a lipase on HD1.

With that said, I am now going to order a lipase on every sick-as-shyte patient.

 

[turkeyjerky]

With that said, I am now going to order a lipase on every sick-as-shyte patient.

That's really a pretty terrible lesson to take from this case.

I doubt I would've ordered a lipase on this guy. In fact, I should say that I definitely would not have.

Sounds to be that the patient's expiration was more related to a delayed intubation rather than a delayed diagnosis of hyperlipasemia.

 

[curbsideconsult]

That's really a pretty terrible lesson to take from this case.

I doubt I would've ordered a lipase on this guy. In fact, I should say that I definitely would not have.

Sounds to be that the patient's expiration was more related to a delayed intubation rather than a delayed diagnosis of hyperlipasemia.

It appears it's a thing to do in very sick patients (such as the one discussed by OP):

Lipase is on our sepsis order set. I typically check in altered patients and critically ill patients.

I'm also very liberal with my lipase ordering. Sepsis, ards, AMS, almost any abdominal complaint, hx of EtOH, etc.

 

[The Knife & Gun Club]

Glad to know I’m not insane, and even gladder to know I’m not the only one who may be much more liberal in ordering lipases down the line.

If I could do it again I’d probably have been a bit more aggressive with my fluids and use the US for some extra reassessments...I think the dude had some fluid tolerance left.

Also wish I’d pulled the trigger to intubated him in the department under more controlled conditions rather than sending him upstairs on bipap given his ABG and general appearance looked crappy. Let ICU pontificate on when to extubate him rather than where his mysterious pancreatitis came from.

This whole medicine thing is surprisingly hard.

 

[turkeyjerky]

It appears it's a thing to do in very sick patients (such as the one discussed by OP):

It's not "a thing to do in very sick patients". It's a thing that two anonymous posters purport to do on an online message board. I won't pretend to analyze their thought processes behind this, but I will simply state, that, in the opinion of this board certified emergency physician, it's a ridiculous practice.

Checking a lipase on every altered or critically ill patient is going to get you a whole lot of false-positive and misleading results. It won't change patient outcomes, but will lead to a great increase in the number of unindicated abdominal CT and US's, as well as GI consults, ordered.

Also, the notion that you would change practice based on an anecdote from a message board is disheartening. No offense to you personally, but this sounds like the type of thinking I would expect from a midlevel.

 

[curbsideconsult]

It's not "a thing to do in very sick patients". It's a thing that two anonymous posters purport to do on an online message board. I won't pretend to analyze their thought processes behind this, but I will simply state, that, in the opinion of this board certified emergency physician, it's a ridiculous practice.

Checking a lipase on every altered or critically ill patient is going to get you a whole lot of false-positive and misleading results. It won't change patient outcomes, but will lead to a great increase in the number of unindicated abdominal CT and US's, as well as GI consults, ordered.

Also, the notion that you would change practice based on an anecdote from a message board is disheartening. No offense to you personally, but this sounds like the type of thinking I would expect from a midlevel.

Is this not the "Student Doctor Network"? This is a place where physicians and physicians-to-be come to get advice from each other. The other two posters I quoted appear to be in EM and one of them is an attending physician such as yourself. You are criticizing my decision to alter my budding practice by 1) going out of your way to insult my educational process and 2) essentially telling me to not to listen to other anonymous posters but instead to listen to you: an anonymous poster.

I hope you are a much better teacher in real life to your residents or that you don't have any residents to teach if your online presence is the same as your real life personality.

 

[curbsideconsult]

Glad to know I’m not insane, and even gladder to know I’m not the only one who may be much more liberal in ordering lipases down the line.

If I could do it again I’d probably have been a bit more aggressive with my fluids and use the US for some extra reassessments...I think the dude had some fluid tolerance left.

Also wish I’d pulled the trigger to intubated him in the department under more controlled conditions rather than sending him upstairs on bipap given his ABG and general appearance looked crappy. Let ICU pontificate on when to extubate him rather than where his mysterious pancreatitis came from.

This whole medicine thing is surprisingly hard.

This is how we learn. The fact that you're still thinking about this after your shift and following up on this patient shows you're doing a great job.

 

[turkeyjerky]

Sorry, I guess I hit a chord, didn't mean to insult you, just wanted to bust your chops a little.

 

[Rekt]

It's not "a thing to do in very sick patients". It's a thing that two anonymous posters purport to do on an online message board. I won't pretend to analyze their thought processes behind this, but I will simply state, that, in the opinion of this board certified emergency physician, it's a ridiculous practice.

Checking a lipase on every altered or critically ill patient is going to get you a whole lot of false-positive and misleading results. It won't change patient outcomes, but will lead to a great increase in the number of unindicated abdominal CT and US's, as well as GI consults, ordered.

Also, the notion that you would change practice based on an anecdote from a message board is disheartening. No offense to you personally, but this sounds like the type of thinking I would expect from a midlevel.

I've never had a false positive on an ams or septic pt unless you're talking about it barely being elevated similar to vomiting levels or something. We can correlate clinically. That just tells me you don't ever see sick biliary/panc pathology. Sorry your panties got in a little bunch.

 

[turkeyjerky]

To each their own. I had an attending snap at me one time in residency b/c I neglected to order a trop and a BNP on a septic patient. That practice stayed with me for way too long until I realized that it wasn't adding anything to management.

 

[WilcoWorld]

To each their own. I had an attending snap at me one time in residency b/c I neglected to order a trop and a BNP on a septic patient. That practice stayed with me for way too long until I realized that it wasn't adding anything to management.

The troponin seems reasonable, but the BNP? Come the **** on!

 

[thegenius]

So I had a case recently which has me a little puzzled.

EMS brings in a dude from local homeless shelter in respiratory distress - has a history of COPD + CHF, they’ve got him on cpap and his vitals are OK, low grade fever, but clearly sick. Mentating fine, no abdominal complaints.

Did the usual stuff in the ED, abx, steroids, careful IVF because of the CHF...labs (including liver stuff) only remarkable for metabolic acidosis and a white count. Notably did not get a lipase. Admitted to ICU, where he promptly decompensates, peri-intubation arrest, ROSC, ends up on 3 pressors, AKI —> renal necrosis, and then finally fulminant liver failure over the course of 72 hours. They never found a source infection.

Somewhere in there someone gets a lipase that came back >4000, and liver ultrasound also happened to see some large gallstones, but no evidence of an obstructing stone or CBD dilation.

Dude dies about 5 days after admission.

ICU attending puts in their final note, that they believe the patient had gallstone pancreatitis causing ARDS missed by the EP because we didn’t get lipase in the ED. I’m biased but feel like the bumped lipase was probably more from multi organ failure/persistent hypotension/pressors.

So my question is...are y’all consistently checking lipases on sick non-abdominal complaints?

Your ICU doctor is a f&$k&$ing d#@ch@#bag if he put in his note "missed by the EP"? He had the f^#@$%k@#h temerity to put that in his note?

 

[s/p epilepticus]

So I had a case recently which has me a little puzzled.

EMS brings in a dude from local homeless shelter in respiratory distress - has a history of COPD + CHF, they’ve got him on cpap and his vitals are OK, low grade fever, but clearly sick. Mentating fine, no abdominal complaints.

Did the usual stuff in the ED, abx, steroids, careful IVF because of the CHF...labs (including liver stuff) only remarkable for metabolic acidosis and a white count. Notably did not get a lipase. Admitted to ICU, where he promptly decompensates, peri-intubation arrest, ROSC, ends up on 3 pressors, AKI —> renal necrosis, and then finally fulminant liver failure over the course of 72 hours. They never found a source infection.

Somewhere in there someone gets a lipase that came back >4000, and liver ultrasound also happened to see some large gallstones, but no evidence of an obstructing stone or CBD dilation.

Dude dies about 5 days after admission.

ICU attending puts in their final note, that they believe the patient had gallstone pancreatitis causing ARDS missed by the EP because we didn’t get lipase in the ED. I’m biased but feel like the bumped lipase was probably more from multi organ failure/persistent hypotension/pressors.

So my question is...are y’all consistently checking lipases on sick non-abdominal complaints?

I feel like you need to have a conversation with either that ICU attending or to someone with your hospital's Risk Management...or both, because there is no place in the chart for comments like that

 

[GeneralVeers]

Your ICU doctor is a f&$k&$ing d#@ch@#bag if he put in his note "missed by the EP"? He had the f^#@$%k@#h temerity to put that in his note?

Is this something that could be brought up to the EM department chair so they could have a talk with the ICU chair about the professionalism of his docs?

 

[thegenius]

Is this something that could be brought up to the EM department chair so they could have a talk with the ICU chair about the professionalism of his docs?

I would f@#$k%$@#ing hope so. I would go straight to admin if you have a good enough relationship with them.

 

[Vandalia]

I would agree this is could go either way. A lipase is not indicated for immediate management, we generally expect our ICU docs to be competent; it isn't going to change much .... since he is going to the ICU. So a decision to not get a lipase is sound EM management.

On the other hand, looking it up, it bills for around $8, which means it has a marginal cost of probably less than $3. In a stay that will likely hit 6 figures, that isn't much. The iatrogenic risk is also negligible given the fact that he is getting labs anyway and going to the ICU.

I don't have a problem with being aggressive in ordering a fairly routine lab test of perhaps marginal value in someone who is sick. The problem is ordering the lipase in the 12 year old who is there because he ate the potato salad that had been sitting out all day in the 90 degree heat.

 

[alpinism]

There's zero indication for a lipase in this patient and the intensivist is being a jackass trying to blame others for his mistakes.

 

[deleted547339]

There's zero indication for a lipase in this patient and the intensivist is being a jackass trying to blame others for his mistakes.

I think your first statement is clearly wrong. You have a critically ill patient that is somewhat undifferentiated. The fact that it turned out to (maybe) be gallstone panc furthers that argument.

 

[deleted547339]

I’m EM/CCM. It seems like you probably should have checked a lipase, but if you rank it from 1-10 on how egregious the error was, it’s a 1 or 2. It’s one of those things that’s it’s nice if you get downstairs, but it doesn’t really change things much if you don’t get it on the front end it. You stabilized him and identified the appropriate disposition. Essentially the only thing that have to be done before someone comes to a Micu is rule out need for expeditious procedural intervention (I.e. cath, surgery, etc) and give time sensitive therapies (e.g. ABx for septic shock). Everything else, I can do upstairs.

I would talk to your medical director ASAP. This needs to go back to the intensivist and his boss ASAP. You can’t put stuff like this in the chart. Not to mention, it is 100% wrong. The intensivist missed the diagnosis as well. Further, unless there was an obstructive biochemical profile of acute liver injury, intervention likely wouldn’t have changed the course. These folks get super sick. If you identify a stone, it can get removed, but LFTs +/- RUQ US would need to be suggestive. And the number of RUQ USs my residents order in the icu is shocking. What determines whether this guy lives or dies is good critical care. It’s essentially 100% supportive. The ED probably contributes a not insiginificant amount to the survival/critical care provided (I dunno, 20%??), but the rest is on him or her.

 

[JacobMcCandles]

I would probably let your risk management team know about this. This kind of documentation will not please them.

 

[alpinism]

I think your first statement is clearly wrong. You have a critically ill patient that is somewhat undifferentiated. The fact that it turned out to (maybe) be gallstone panc furthers that argument.

The post states he was having typical CHF/COPD symptoms with normal mental status and vital signs.

He was most certainly sick but didn't become critical and decompensate until he left the emergency department.

 

[Rekt]

The post states he was having typical CHF/COPD symptoms with normal mental status and vital signs.

He was most certainly sick but didn't become critical and decompensate until he left the emergency department.

I mean we're all essentially guessing what he actually looked like/vitals/workup. Kind of a moot point. If someone immediately decompensates upon arriving to the floor, they sound fairly critically ill and likely underresuscitated.

 

[WilcoWorld]

How does this documentation even help the intensivist?

Plaintiff's attorney: Doctor, I see here you wrote that you "believe the patient had gallstone pancreatitis causing ARDS missed by the EP because he didn’t get lipase in the ED."

Dr. ICUpants: That's correct.

Plaintiff's attorney: So your expert opinion is that this diagnosis should have been suspected and investigated upon arrival to the hospital, is that correct?

Dr. ICUpants: That's correct.

Plaintiff's attorney: Doctor, if this diagnosis should have been suspected and investigated upon arrival to the hospital why did it take you several days to make that diagnosis in the Intensive Care Unit?

 

[deleted547339]

The post states he was having typical CHF/COPD symptoms with normal mental status and vital signs.

He was most certainly sick but didn't become critical and decompensate until he left the emergency department.

Yea, maybe. It’s tough to say based on a retrospectively biased second hand story. Regardless, we can all agree that the icu doc in question needs to hear about it from the chair of EM and director of the icu. Although my guess is 1) he is super new and this sort of crap was ok at his or her last institution 2) this is a pretty messed up hospital with a long history of poor relationships between EM and CCM, which is sad.

 

[The Knife & Gun Club]

Yea I don’t think the attending was acting in bad faith at all here. I’ve worked with this attending before and they’re not known to be particularly malignant to crispy.

If I had to guess, we’re a big teaching hospital, so there’s a decent chance the attending just copied forward something a resident or fellow wrote without really thinking about it.

It comes up not infrequently here since we get a lot of FMG residents/fellows - they think it’s fine to bag on the ED in person or documentation because in their home country EM doesn’t really exist and medicolegal issues are much less prominent. It takes a few months to break that habit.

 

[Siggy]

The troponin seems reasonable, but the BNP? Come the **** on!

Meh. In general the elevated troponin in the septic patient is representative of acute myocardial injury that is likely to be misdiagnosed as a type 2 NSTEMI (since technically the NSTEMI diagnosis is going to require chest pain, EKG changes, or new wall motion abnormality in addition to the rise and fall of troponin. See 4th Universal Definition of MI)... for which the treatment is going to be treat the sepsis.

 

[CajunMedic]

Not routinely. Probably not at all on this patient. Wouldn't have likely changed my management. I probably would have stayed on the CHF/COPD/Sepsis route

I somewhat feel your pain. One shift, the least sick of the 3 I was running around trying to keep alive, was a floridly fluid overloaded, non-compliant renal patient who was also septic. My attending and I felt that they likely needed pressors and continuous dialysis once they hit the ICU. Sure as heck wasn't going to give them 30 mg/kg of fluid and a bunch of antibiotics that were going to dialyze out. Called renal and got that set up, got what I needed to get to admit to the ICU and try to dispo. Resident gives me a bunch of pushback, the ICU attending comes down and starts raising hell. Orders 3L of fluid, Vanc, zosyn, etc. and leaves. I step out for 5 minutes to grab a Dr. Pepper, ICU attending is coming back down for something, catches me at the Coke machine and starts raising hell about what we did and didn't do. Then they call again and try to bitch at my attending. The expected happens, the patient crashes from pulmonary edema, and they ask if we want to intubate and put in the central line. My attending says "Hell no, we've got a department and a waiting room full"

Dies 5 days later

In the chart: "Patient was inadequately resuscitated by the ED." I swear that was the longest MDM I have ever written.

 

[NITRAS]

Not routinely. Probably not at all on this patient. Wouldn't have likely changed my management. I probably would have stayed on the CHF/COPD/Sepsis route

I somewhat feel your pain. One shift, the least sick of the 3 I was running around trying to keep alive, was a floridly fluid overloaded, non-compliant renal patient who was also septic. My attending and I felt that they likely needed pressors and continuous dialysis once they hit the ICU. Sure as heck wasn't going to give them 30 mg/kg of fluid and a bunch of antibiotics that were going to dialyze out. Called renal and got that set up, got what I needed to get to admit to the ICU and try to dispo. Resident gives me a bunch of pushback, the ICU attending comes down and starts raising hell. Orders 3L of fluid, Vanc, zosyn, etc. and leaves. I step out for 5 minutes to grab a Dr. Pepper, ICU attending is coming back down for something, catches me at the Coke machine and starts raising hell about what we did and didn't do. Then they call again and try to bitch at my attending. The expected happens, the patient crashes from pulmonary edema, and they ask if we want to intubate and put in the central line. My attending says "Hell no, we've got a department and a waiting room full"

Dies 5 days later

In the chart: "Patient was inadequately resuscitated by the ED." I swear that was the longest MDM I have ever written.

You didn’t give your septic patient antibiotics because they were going to dialysis?

 

[CajunMedic]

You didn’t give your septic patient antibiotics because they were going to dialysis?

That was the thought. We felt they would be dialyzed out and better to get them afterwards

 

[Rekt]

That was the thought. We felt they would be dialyzed out and better to get them afterwards

I'll be the bad guy here. This was a bad move. You absolutely give antibiotics regardless if a patient is going for "emergent" dialysis or not. Also this is discussed ad nauseum here, but volume overload is not a contraindication for IVF. Especially since there's a significant difference of where that volume is located. Intra vs extra vascular, etc.

 

[Dr Mantis Toboggan]

I'll be the bad guy here. This was a bad move. You absolutely give antibiotics regardless if a patient is going for "emergent" dialysis or not. Also this is discussed ad nauseum here, but volume overload is not a contraindication for IVF. Especially since there's a significant difference of where that volume is located. Intra vs extra vascular, etc.

Yeah but I think pressors only are a better move in people floridly drowning. I document as such and take the hit with the nurse reviewers.

 

[DeadCactus]

I'm really struggling to think what I would do with an elevated lipase besides admit a stable abdominal pain patient to the floor for fluids and symptomatic management. I try to imagine a hypothetical patient and each time just conclude I would get a CT abdomen on a septic patient without a clear source (or a clearly abdominal source) long before I started thinking a lipase would be the solution to all my problems.

I'm really worried; if I missed L in the ABC's then I must have missed FGHIJK too.

 

[Porfirio]

The CLOVERS trial results will be helpful, but an early vasopressor strategy also appears beneficial. Run them peripherally. Most people don't need a central line.

Effects of very early start of norepinephrine in patients with septic shock: a propensity score-based analysis

I wish most didn’t require a central line. But no one in my world admits without one and on levo.

 

[Xerxes1729]

I'm pretty liberal with checking lipase. As people have mentioned, it's an inexpensive noninvasive test that might significantly change your management. And, unlike troponin, if it comes back minimally elevated I don't feel compelled to do anything about it. My general practice is that if I'm ordering blood work for an abdominal complaint, and especially if I'm ordering LFTs, I also order lipase.

I've found pancreatitis with lipase greater than assay in an 80yo whose only symptom was two days of intractable hiccups and in a 10yo with multiple ED visits over the last six months for upper abdominal pain.

The intensivist in the OPs post is ridiculous, however, and should not have written that in the chart.

 

[Zebra Hunter]

That was the thought. We felt they would be dialyzed out and better to get them afterwards

I have to agree that it is a very bad move to not start antibiotics immediately in a septic shock patient. That is pretty indefensible, and I would probably be pretty furious with your attending, as well. In renal patients with septic shock and evidence of pulmonary edema, I will give some fluids and reassess frequently while starting vasopressors very early. Another move that was a bit questionable was your attending refusing to help with at least intubation. I get not doing a central line given it is time consuming and not necessary to start pressors nor a life saving intervention, but if a ICU colleague asks if I'd be able to intubate a patient of theirs, even if I never saw them, my answer is never "no, I'm too busy" unless you are literally in the middle of coding someone, especially for a patient you saw that is still sitting in the ER. Helping out colleagues goes a long way to improving relationships between your departments.

I actually had a colleague recently do something similar, although more egregious. I occasionally pick up shifts in the ICU to help out our intensivists given they are swamped with COVID. I got a consult from one of my EM colleagues for an admission for a patient with COPD on bipap needing the ICU for hypercapnic respiratory failure. I review the chart and see the patient came in with a VBG w/ a pH of 7.15, pCO2 of 100. Repeat VBG an hour later was a pH of 7.05, pCO2 of 120. I go and see the patient and they are minimally responsive. I ask RT how long the patient has been like this, and he states literally since arrival two hours prior. I ask my colleague if they saw the repeat gas, or saw that the patient was clearly severely altered. "Yeah, that's why they need the ICU." I ask if they at least made any changes to the bipap settings, like increasing the delta P? "No, I don't have time for that right now." Granted she was busy, although the department was no more busy that what I typically deal with on occasion. I ask if she would like to intubate the patient, as the patient clearly requires mechanical ventilation at this point. Her response was a frustrated "No, I don't have time, and that's why I consulted you." I walked off, intubated the patient, then came back into the room she was in. I proceeded to verbally go down the list of patients she was currently caring for "Ankle pain, abdominal pain, vaginal bleeding, headache, nausea, shoulder pain." I then asked her which one of these patients was sicker than the patient I just intubated for you? Because clearly one of these patients must have been sick as **** for her to ignore the crashing hypercapnic patient that she neglected for two hours. I told her I hoped she was just doing this because she knew I was on and that she normally doesn't do this bull**** to our actual intensivist colleagues, because this was the sickest patient in the department, and you are never "too busy", for your sickest patient.

 

[BoardingDoc]

That was the thought. We felt they would be dialyzed out and better to get them afterwards

Gotta agree with @Rekt here. I can understand not giving fluids and simply starting pressors if you're worried about volume status, but not giving abx to a septic patient, whether they're going to dialysis or not, is just a bad call.

If you're honestly worried about the abx getting dialyzed out, just redose them after HD. Also, if they need pressors "once they get to the ICU" why the heck didn't you start pressors in the ED? Just run them peripherally if you don't have time for a CVL.

Maybe this case just isn't being portrayed correctly and maybe the outcome wouldn't have changed, but from what you've written, I definitely don't think this case was handled well.

 

[SpacemanSpifff]

Gotta agree with @Rekt here. I can understand not giving fluids and simply starting pressors if you're worried about volume status, but not giving abx to a septic patient, whether they're going to dialysis or not, is just a bad call.

If you're honestly worried about the abx getting dialyzed out, just redose them after HD. Also, if they need pressors "once they get to the ICU" why the heck didn't you start pressors in the ED? Just run them peripherally if you don't have time for a CVL.

Maybe this case just isn't being portrayed correctly and maybe the outcome wouldn't have changed, but from what you've written, I definitely don't think this case was handled well.

That was the thought. We felt they would be dialyzed out and better to get them afterwards

Without getting into the weeds on drug metabolism in patients requiring renal replacement therapy, a couple quick points:

1. The need for CRRT or HD should not affect your decision to give antibiotics if clinically indicated in the ED. If this patient was going to get CRRT, that would affect the schedule of the antibiotic dosing, which would be an ICU decision.

2. If you have questions about any drug utilize your resources, specifically pharmacists. These are the drug experts and should be more than ready to help with any questions you have. If you have an ED pharmacist, excellent. If you don't, ask the folks staffing the central pharmacy.

3. Use this as a learning case. It's tough to think that the people responsible for your education could be mistaken, but it happens. One of the marks of an excellent doc/educator is owning up to these mistakes. Those attendings are the ones you want to emulate.

 

[Dr Mantis Toboggan]

I have to agree that it is a very bad move to not start antibiotics immediately in a septic shock patient. That is pretty indefensible, and I would probably be pretty furious with your attending, as well. In renal patients with septic shock and evidence of pulmonary edema, I will give some fluids and reassess frequently while starting vasopressors very early. Another move that was a bit questionable was your attending refusing to help with at least intubation. I get not doing a central line given it is time consuming and not necessary to start pressors nor a life saving intervention, but if a ICU colleague asks if I'd be able to intubate a patient of theirs, even if I never saw them, my answer is never "no, I'm too busy" unless you are literally in the middle of coding someone, especially for a patient you saw that is still sitting in the ER. Helping out colleagues goes a long way to improving relationships between your departments.

I actually had a colleague recently do something similar, although more egregious. I occasionally pick up shifts in the ICU to help out our intensivists given they are swamped with COVID. I got a consult from one of my EM colleagues for an admission for a patient with COPD on bipap needing the ICU for hypercapnic respiratory failure. I review the chart and see the patient came in with a VBG w/ a pH of 7.15, pCO2 of 100. Repeat VBG an hour later was a pH of 7.05, pCO2 of 120. I go and see the patient and they are minimally responsive. I ask RT how long the patient has been like this, and he states literally since arrival two hours prior. I ask my colleague if they saw the repeat gas, or saw that the patient was clearly severely altered. "Yeah, that's why they need the ICU." I ask if they at least made any changes to the bipap settings, like increasing the delta P? "No, I don't have time for that right now." Granted she was busy, although the department was no more busy that what I typically deal with on occasion. I ask if she would like to intubate the patient, as the patient clearly requires mechanical ventilation at this point. Her response was a frustrated "No, I don't have time, and that's why I consulted you." I walked off, intubated the patient, then came back into the room she was in. I proceeded to verbally go down the list of patients she was currently caring for "Ankle pain, abdominal pain, vaginal bleeding, headache, nausea, shoulder pain." I then asked her which one of these patients was sicker than the patient I just intubated for you? Because clearly one of these patients must have been sick as **** for her to ignore the crashing hypercapnic patient that she neglected for two hours. I told her I hoped she was just doing this because she knew I was on and that she normally doesn't do this bull**** to our actual intensivist colleagues, because this was the sickest patient in the department, and you are never "too busy", for your sickest patient.

Savage. I like it.

 

[WilcoWorld]

Meh. In general the elevated troponin in the septic patient is representative of acute myocardial injury that is likely to be misdiagnosed as a type 2 NSTEMI (since technically the NSTEMI diagnosis is going to require chest pain, EKG changes, or new wall motion abnormality in addition to the rise and fall of troponin. See 4th Universal Definition of MI)... for which the treatment is going to be treat the sepsis.

Yeah, I know. That's why I only went so far as to call it "reasonable". My main point was that a BNP is especially useless in such a case.

Want a walk down memory lane? Who remembers this "smackdown" thread? DocB, mudphud, Roja...and, of course @Apollyon and @southerndoc make appearances.

 

[southerndoc]

I wish most didn’t require a central line. But no one in my world admits without one and on levo.

The issue is extravasation. Low doses of a pressor are OK through a peripheral IV so long as it doesn't extravasate. Large doses, however, really should be given through a CVL.