When to Check a Lipase?

[southerndoc]

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.

I agree the patient should have been intubated, but each doc has their own version of drowning. Perhaps she had just been dressed down by her medical director over her patient satisfaction scores and the patients she had on her list were being demanding. Maybe she was overwhelmed with family problems. We each have our weaknesses that vary day to day.

While I think you're right that she should've intubated the patient, she was reaching out to you to help her. She should've been more clear with it ("hey, I'm really drowning here, can you help me intubate this patient?") instead of just saying the patient needs ICU admission.

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[southerndoc]

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.

This is more indefensible than asking for help from an ICU doc in a patient who needs intubation. Failure to give antibiotics quickly in a septic patient increases mortality for each hour that passes. It's the most important treatment in sepsis.

 

[deleted547339]

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.

Tough to say if the fluids were or were not appropriate without seeing the patient.

Saying not giving antibiotics is malpractice is like saying Jeffery Epstein wasn’t a great baby sitter. Holy cow, that’s absurd. Like, it should get your attending fired bad. Based on that logic, we shouldn’t give aspirin or lytics because the coronary is clogged, or oxygen to people with pneumonia because they have filled alveoli. Frankly, based on what you said about your attending and the intensivists response, I am more likely to believe the intensivist is right.
It’s also 100% possible they crumped because they, in fact, we’re under-resuscitated.

 

[deleted547339]

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.

Yes, but identifying that 1) changes your O:E for which you are reimbursed based on 2) increases your level of complexity and 3) can rarely be a clue that the patient has suffered an ACS event in the case of rising trop (admitted vanishingly small). I would argue you should get one on anyone with hemodynamic instability or who is already heading to the unit. Again, $$$$.

 

[RoyBasch]

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.

I don't think a proBNP is useless here, it gives you some indication of heart failure and volume status. If it's completely normal, it makes me tend to think I can be more aggressive with fluids. If its significantly elevated (above baseline elevation), perhaps I need to tend towards pressors sooner and fewer fluids.

Full disclaimer: this isn't an absolute guideline, but in a patient that is going to have complex hemodynamics and fluid status I'll take as many datapoints as I can get. Certainly proBNP is tabulated in addition to clinical exam volume status, serial vitals/hemodynamic markers, CXR, bedside US, etc.

At the end of the day, I think this thread kind of circles around that a lot of biochemical markers are going to be abnormal in critically ill patients; however, these tests are not simply positive or negative, they are continuous variables and the degree to which they are abnormal can provide information. Significant perturbation of one of these variables can suggest what the primary process actually is rather than just secondary to whatever substantial underlying etiology is going on. At it's core its a "signal vs. noise" conundrum.

 

[deleted547339]

I don't think a proBNP is useless here, it gives you some indication of heart failure and volume status. If it's completely normal, it makes me tend to think I can be more aggressive with fluids. If its significantly elevated (above baseline elevation), perhaps I need to tend towards pressors sooner and fewer fluids.

Full disclaimer: this isn't an absolute guideline, but in a patient that is going to have complex hemodynamics and fluid status I'll take as many datapoints as I can get. Certainly proBNP is tabulated in addition to clinical exam volume status, serial vitals/hemodynamic markers, CXR, bedside US, etc.

At the end of the day, I think this thread kind of circles around that a lot of biochemical markers are going to be abnormal in critically ill patients; however, these tests are not simply positive or negative, they are continuous variables and the degree to which they are abnormal can provide information. Significant perturbation of one of these variables can suggest what the primary process actually is rather than just secondary to whatever substantial underlying etiology is going on. At it's core its a "signal vs. noise" conundrum.

I know I’ve said this before, but love the name.

 

[RoyBasch]

I know I’ve said this before, but love the name.

Thanks!

 

[RustedFox]

I know I’ve said this before, but love the name.

It gets me every time too, homey.

 

[WilcoWorld]

I don't think a proBNP is useless here, it gives you some indication of heart failure and volume status. If it's completely normal, it makes me tend to think I can be more aggressive with fluids. If its significantly elevated (above baseline elevation), perhaps I need to tend towards pressors sooner and fewer fluids.

Full disclaimer: this isn't an absolute guideline, but in a patient that is going to have complex hemodynamics and fluid status I'll take as many datapoints as I can get. Certainly proBNP is tabulated in addition to clinical exam volume status, serial vitals/hemodynamic markers, CXR, bedside US, etc.

At the end of the day, I think this thread kind of circles around that a lot of biochemical markers are going to be abnormal in critically ill patients; however, these tests are not simply positive or negative, they are continuous variables and the degree to which they are abnormal can provide information. Significant perturbation of one of these variables can suggest what the primary process actually is rather than just secondary to whatever substantial underlying etiology is going on. At it's core its a "signal vs. noise" conundrum.

Fair enough. pro-BNP isn't going to be the first lab I check on a sick sepsis patient, but if you wanted to order one I wouldn't give you a hard time about it. I was responding to someone who's attending scolded them & told them every septic patient needs a BNP - that's the attitude I'm arguing against.

 

[thegenius]

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.

God I remember these days as a resident. Just so much bullshiit.

It's not like the bullshiit stops in a community hospital but it's a lot less thankfully.

 

[thegenius]

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

Yup and therein lies the problem.

 

[deleted547339]

Time to work with your intensivists to bring them up to speed on peripheral pressors. We convinced our intensivists to start using them and it has made everything a lot easier. Pressors get started more often, less SEP-1 bundle fallouts, patients don’t have to experience a central line placement, and they often come off pressors within 24 hours.

Yea. I usually line them up around 8-12 hours. It’s not an opposition to running them longer, it’s just that I feel like if they aren’t off pressors by then, the number that will go off and stay off is pretty low. That being said, there are plenty of times I’ve run relatively low dose pressors through a PIV for some days.

 

[thegenius]

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.

What was your goal in making her feel bad, angry, and probably get defensive?

This, to me, is almost akin to writing in your chart "ED failed to properly manage this patient."

While what you said was out loud and not-documented, it just seems petty.

 

[WilcoWorld]

What was your goal in making her feel bad, angry, and probably get defensive?

This, to me, is almost akin to writing in your chart "ED failed to properly manage this patient."

While what you said was out loud and not-documented, it just seems petty.

Yeah, sounds like emotions were running high all around that day.

 

[Zebra Hunter]

What was your goal in making her feel bad, angry, and probably get defensive?

This, to me, is almost akin to writing in your chart "ED failed to properly manage this patient."

While what you said was out loud and not-documented, it just seems petty.

The goal is to make sure she doesn’t do this again. It’s completely inappropriate. She had no clue I was in house as most of the intensivists at this hospital take call from home overnight, and made no mention on the phone that she believed the patient required intubation. This patient was dying while she ignored them to handle non-emergencies. That kind of behavior needs to be stamped out, and one should speak up when they see it in colleagues.

 

[Siggy]

Yes, but identifying that 1) changes your O:E for which you are reimbursed based on 2) increases your level of complexity and 3) can rarely be a clue that the patient has suffered an ACS event in the case of rising trop (admitted vanishingly small). I would argue you should get one on anyone with hemodynamic instability or who is already heading to the unit. Again, $$$$.

I didn't think that 99291 mattered in regards to medical complexity that would hinge on a troponin in the settings of septic shock. In an undifferentiated shock or even a sudden onset of heart failure (decompensated HF will also cause an elevated troponin, but ACS can put a patient into heart failure) then sure. However how often are you starting ACS management (DAPT/anticoagulation) in a septic shock patient with a positive troponin?

I guess it could add an MCC to the DRG, but even then most of my septic shock patients has more then enough secondary diagnosis that proper documentation would pick up the MCC. It's like the argument I had with administration during fellowship when they said that we needed to add NSTEMI to our PE patients getting EKOS in order to justify it. Most didn't have that second part of the NSTEMI diagnosis, but documenting acute cor pulmonale due to RV dilation counted as an MCC anyways.

 

[The Knife & Gun Club]

What was your goal in making her feel bad, angry, and probably get defensive?

This, to me, is almost akin to writing in your chart "ED failed to properly manage this patient."

While what you said was out loud and not-documented, it just seems petty.

Curious how you think situations like this should be handled? Maybe hit up the medical director and relay a complaint? Try to bring it up with the EP in a way that’s a little less hostile (I imagine it was probably less hostile than it sounds online)?

 

[deleted547339]

I didn't think that 99291 mattered in regards to medical complexity that would hinge on a troponin in the settings of septic shock. In an undifferentiated shock or even a sudden onset of heart failure (decompensated HF will also cause an elevated troponin, but ACS can put a patient into heart failure) then sure. However how often are you starting ACS management (DAPT/anticoagulation) in a septic shock patient with a positive troponin?

I guess it could add an MCC to the DRG, but even then most of my septic shock patients has more then enough secondary diagnosis that proper documentation would pick up the MCC. It's like the argument I had with administration during fellowship when they said that we needed to add NSTEMI to our PE patients getting EKOS in order to justify it. Most didn't have that second part of the NSTEMI diagnosis, but documenting acute cor pulmonale due to RV dilation counted as an MCC anyways.

I may be wrong, but I was under the impression the more high risk present on admission diagnoses, the higher the expected mortality and the better your hospital looks.

And like I said, the third was vanishingly rare, but not zero.

 

[Siggy]

I may be wrong, but I was under the impression the more high risk present on admission diagnoses, the higher the expected mortality and the better your hospital looks.

That I cannot answer. I always thought that mortality and LOS/GLOS was based off of the DRG more than anything else. I do agree that making the hospital/yourself look good by trying to maximize the expected mortality, length of stay, and case mix index are good things and tend to be underemphasized in training. Keeping a patient alive is important, but so is keeping a job.

 

[Tenk]

If someone wrote that in a chart about me and I found out about it, I would track them down and talk to them face to face.

They would never write anything like that about me again.

 

[thegenius]

Curious how you think situations like this should be handled? Maybe hit up the medical director and relay a complaint? Try to bring it up with the EP in a way that’s a little less hostile (I imagine it was probably less hostile than it sounds online)?

I don't know. It's not an easy thing to address. The EP was clearly wrong, that is without question. All I know is I doubt the relationship between zebra and the EP got better. Probably just got worse. Maybe send an email a day or two later (after emotions have simmered) to ER leadership?

There are numerous times I disagree with how other docs, especially ICU and hospitalists, treat their patients. This one is pretty bad admittedly.

 

[Radetzky]

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?

The patient may indeed have had inflammation of the pancreas at some point during their stay but the picture in the first 24 hours you describe sounds very unlikely for pancreatitis being the presenting problem.

Did he get abdominal imaging at any point?

 

[emergentmd]

#1 the CC doc is a major Dick. I would go to admin and get him reprimanded. I would push this chart to peer review and get it looked at. If all fails, I would go up to him/her and tell them if this ever happens again I will make his life miserable. He will get a page at 3am every shift he works asking him for his expert opinion.

#2 I will put this in my bucket of, "Yeah I was told to do this but after 20 years as an attending I will not". In the same bucket as Pelvic exam for all vag bleed, Rectal exam for all abdominal pain, LP for worse headache of my life.

#3 Getting the lipase in the ER would have ZERO affect on the outcome. Even if Knowing a lipase would change this guys outcome, what happened to the countless hours where it wasn't ordered.

 

[RoyBasch]

#3 Getting the lipase in the ER would have ZERO affect on the outcome. Even if Knowing a lipase would change this guys outcome, what happened to the countless hours where it wasn't ordered.

Seriously this.

If they were so convinced knowing a lipase would dramatically alter this case (it will not), then they could have ordered the lab themselves immediately after their initial history and physical exam, or at ANY TIME over the next 5 days.

Sometimes I really think we are the only physicians who actually "think" about cases, so many just continue the plan devised by the ER.

The fact that a patient is ill and in a dynamic situation--which can change--and the care needs to evolve/adapt accordingly, is the impetus to admit patients to a carefully monitored setting (i.e. the hospital, and more specifically he ICU).

 

[jw3600]

Am I taking crazy pills? A board certified attending had a MDM/plan that mentioned NOT giving antibiotics in septic shock because of possible hemodialysis later? That is truly absurd.

 

[Apollyon]

I've said it before, but, it bears repeating: some animals have to live in the zoo, because they can't survive in the wild. I'll bet, dollars to doughnuts, that the CC doc mentioned above is academic, where someone can be a TOTAL ***hole and get away with it, cleanly, and the other guy, with the HD pt and the abx, is, ipso facto, academic.

 

[Angry Birds]

What was your goal in making her feel bad, angry, and probably get defensive?

This, to me, is almost akin to writing in your chart "ED failed to properly manage this patient."

While what you said was out loud and not-documented, it just seems petty.

Well, she deserved it. And yeah, she'll think twice next time.

 

[deleted547339]

I've said it before, but, it bears repeating: some animals have to live in the zoo, because they can't survive in the wild. I'll bet, dollars to doughnuts, that the CC doc mentioned above is academic, where someone can be a TOTAL ***hole and get away with it, cleanly, and the other guy, with the HD pt and the abx, is, ipso facto, academic.

Key word: some.

There are plenty of us in academics who can still move the meat.

 

[WheezyBaby]

Well, she deserved it. And yeah, she'll think twice next time.

If I left a patient unattended for hours in worsening respiratory failure Id hope someone would dress me down. I'm not for antagonism, but I feel like sometimes you just need to say "hey what the **** is this ****ery get your **** together"

 

[Dr Mantis Toboggan]

If I left a patient unattended for hours in worsening respiratory failure Id hope someone would dress me down. I'm not for antagonism, but I feel like sometimes you just need to say "hey what the **** is this ****ery get your **** together"

Yup the fact that this lady didn’t immediately apologize and run in there to do the right thing is telling.

 

[Apollyon]

Key word: some.

There are plenty of us in academics who can still move the meat.

Yeah, I said "some". It's a LOT easier to go from the community to an academic shop, but the personality disorders that people show will, with very little exception, be in academic shops, because HR won't stand for any of this ****ery in "the real world".

"The real world? What, like, Reseda?" <-- name the movie?