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Critical Care Concerns: Listener Questions - Fluids in Sepsis and Renal Failure

Rob Orman, MD and Scott Weingart, MD
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EM:RAP October 2013 Written Summary 2 MB - PDF

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Mark S. -

What would your target be for a MAP in these patients? Renal perfusion is presumably less important than in other patients, if we are talking end-stage. The volumes of fluid make me nervous as one will invariably have to dialyse that fluid off and there can be quite a delay time between decision to dialyse and it actually happening, by whatever means (CVVHDF or usual haemodialysis). As long as the patient is alert and talking, I tend to opt for a conservative MAP, give 250ml crystalloid boluses up to 1 - 2 litres and reach early for pressors.

Interested in your thoughts re: MAP target. Thanks.

EMCrit -

MAP target is to perfuse the heart and the microcirculation of the tissues. The fact that the fluid will need to be dialyzed off is irrelevant, they will be putting most of this fluid into the interstitium. They will need HD regardless of whether you give fluid or not in the ED.

Mimi L., M.D. -

How do you like to approach patients (fluid wise) with severe sepsis or septic shock that are also in CHF 2/2 myocardial injury from their sepsis?

EMCrit -

Inotropes until heart function is better, then IVC will start collapsing again--give more fluid at that point

Colin Kaide, M.D. -

If you are "machine," I vwant parrrty vis you! большое спасибо господину машины

Peter L. -

Hey Scott,
My question is about the sensitivity of venous lactate and how they are analyzed. We run our lactates off a grey top on ice and not on the ABG machine. From what I understand, you are saying that there is a difference in outcomes if I run the same venous blood through a blood gas machine vs spinning it down in my grey top. Is this difference clinically significant? Other than the time factor, should we be running our lactates through the blood gas machine every time?

EMCrit -

Colin, it would be my pleasure. Вы Welcom

EMCrit -


Amil B. -

Are the any studies comparing venous blood gas lactate versus venous gray top lactate? From what I understand, the previous comparisons have been between arterial and venous. The gas comes back quicker, but is there a difference quantitatively? If so, which is considered “gold standard “?

EMCrit -

Amil, Have not seen a study, only reports of simultaneously drawn samples. There are at least 3 studies comparing arterial and venous on same blood gas machine showing no discrepancy. By inference the problem therefore is the machine not the source. There is a difference, blood gas machine is what all of the egdt studies and lactate clearance studies have used.

steve r. -

Hi Scott

I have spoken with our lab regarding lactic acid samples and found that we are running them in lab with assay, not on blood gas machine (both arterial and venous smaples run this way at our facility). We are a small community hospital and it seems cost is not insignificant to set up system to run on blood gas machine. Do we need to consider switching how we analze lactic acid, regardless of cost??


EMCrit -

Steve, On this particular issue, I would say cost is so negligible as to be a non-issue. Machine costs less than $20,000. Samples will cost less than current lactate testing. Also opens the door to <10 minute INR, K, HCT, etc.

Jeffrey D., P.A. -

Hey Scott, I brought this up with our lab and ER director, and they are looking for any papers, studies or statements to this matter to help facilitate this change to using the cooximeter instead of the assay. Are there any?

EMCrit -


The Jones trial and the Rivers trial both used venous on blood gas analyzer:

These 3 used arterial and venous on the same machines:
19. Lavery RF, Livingston DH, Tortella BJ, Sambol JT, Slomovitz BM, Siegel JH. The utility of venous
lactate to triage injured patients in the trauma center. J Am Coll Surg 2000;190:656-
20. Younger JG, Falk JL, Rothrock SG. Relationship between arterial and peripheral venous lactate levels.
Acad Emerg Med 1996;3:730-
21. Middleton P, Kelly AM, Brown J, Robertson M. Agreement between arterial and central venous
values for pH, bicarbonate, base excess, and lactate. Emerg Med J 2006;23:622-

Pamela S. -

Hi Scott, I read the above posts with interest, reviewed your emcrit site but still have a question. I checked with our lab and they tell me that our blood gas machine is not capable of running lactates. What to do now? I'm having a hard time convincing our hospital to change practice because I heard it on EM: Rap. More data would be appreciated. Moving forward, do I still order the grey top lactates or are they useless? I'm thinking we can trend the levels but might not be able to use 4.0 as definitive cutoff. I'd appreciate your thoughts.
Thanks, Pamela

Patrick B. -

Had an 18yo patient other month with toxic shock who defied what you guys are saying about flooding the young and healthy (as I always have done with young septic shock)...after the 2nd L, she had coughing and had pulmonary edema on the CXR to confirm the line...myocardial stunning with EF of 18% that of course was improved prior to DC but was a big surprise for me...

EMCrit -

Patrick-You lost me brother. Pt flooded due to sepsis-induced cardiac stun, not your 2 liters. This pt needs a tube, inotropes, and then further fluids, not to be kept dry.


Patrick B. -

Yes agree 100%. It was just the first time that I had seen this and although not sure I harmed her, it was one of those uncommon young healthy patients whose LV wasn't initially prepared to mobilize the bolus she appeared to warrant....apparently myocardial stunning is well described in TSS. Not a practice changer it was just an interesting experience, I shall continue to flood the young and healthy and tube/dobutamine where indicated....thanks for what you guys do, became an devout listener this year


Dottie M.D. -

Hi Scott,

Thanks for the references above. Do you have any evidence/papers on proving analyzers are inaccurate or inferior to blood gas machines for lactate results?


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Episode 145 Full episode audio for MD edition 218:18 min - 103 MB - M4AEM:RAP Resumen October 2013 Español 97:28 min - 67 MB - MP3EM:RAP 2013 October MP3 266 MB - ZIPEM:RAP October 2013 Written Summary 2 MB - PDFEM:RAP October 2013 Board Review Questions 641 KB - PDFEM:RAP October 2013 Board Review Answers 658 KB - PDF

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