WBC 19, Lactic Acid 3.2, but not septic?

  1. 0 My patient came into the hospital with hypotension and r/o sepsis. SBP 69, WBC 19, Lactic Acid 3.2, HR 90's in chronic Afib, RR 20, afebrile. There did not appear to be any infection. She has a cocktail of PMH including CHF, DM, home 02...etc. They think that after her OP doc added another diuretic she went hypotensive. Once her BP was stable they were ready to let her go. Her WBC's did come down to 13 the next day before discharge.

    I'm thinking the LA perhaps was high due to dehydration following rapid diuresis. But would the LA be that high? Would this elevate the WBC's? I was thinking he might take a closer look for an infection source but the doc seemed happy with sending her out. Any thoughts?
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  3. Visit  Turtle in scrubs profile page

    About Turtle in scrubs

    Joined Mar '07; Posts: 189; Likes: 201.

    11 Comments so far...

  4. Visit  jlr820 profile page
    2
    When you say "There did not appear to be any infection..." can you elaborate? Were blood cultures performed? Urinalysis? Stool sample for CDiff toxins? Any wounds? The WBC was 19, but what was the differential? As for the lactic acid, Mosby's Diagnostic and Lab Test Reference says that (in addition to shock states, and tissue hypoxia) diabetes can increase lactic acid. Severe liver disease can as well. Perhaps her DM was a factor. What other signs and symptoms was she exhibiting on admission? Any recent trauma? As for the leukocytosis, obviously infection can cause it, but so can inflammation, leukemia, trauma, tissue necrosis, and various types of stress. Whatever caused the hypotension (diuresis, or her heart failure itself or both) could have put her into hypovolemic shock and that could account for the elevated LA level and the leukocytosis (from physiologic "stress).
    Last edit by jlr820 on Apr 13, '10
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  5. Visit  medicrn13 profile page
    1
    http://www.webmd.com/a-to-z-guides/lactic-acid

    Some information on lactic acid.

    Also if her white count decreased that much without the use of anti-microbials, that may have lead them to believe that it was a stress reaction as well.

    She doesn't really present with all the classic signs/symptoms of sepsis (fever or low temp, tachycardia, tachypnea...) Really just that pesky blood pressure, white count and lactic acid level.
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  6. Visit  Turtle in scrubs profile page
    0
    No BC or other tests to r/o infection.

    I understand that LA can be elevated for many reasons. Just wondering from those of you out there who have seen a lot of it if 3.2 makes senses... that is not exactly a small bump. I've seen an elevated LA for other reasons, but they were all just a bit elevated. Anything I've seen over about 2 has been in conjunction with sepsis. But that is why I'm asking b/c I haven't seen all that many.

    You are probably right about the WBC and the stress rxn b/c they came right down.

    oh.. not only is she diabetic but on metformin, which can elevate LA... but really, that much?
  7. Visit  Spacklehead profile page
    0
    I was just going to ask if your pt was on metformin for the DM! That is one of the serious side effects of taking metformin - how was the kidney and liver function?
  8. Visit  Spacklehead profile page
    0
    Also, did they check cardiac enzymes, EKG?
  9. Visit  Turtle in scrubs profile page
    0
    Quote from Softballmama
    I was just going to ask if your pt was on metformin for the DM! That is one of the serious side effects of taking metformin - how was the kidney and liver function?
    Both kidney and liver function were fine.
  10. Visit  Turtle in scrubs profile page
    0
    Quote from Softballmama
    Also, did they check cardiac enzymes, EKG?
    Cardiac enzymes were fine. Don't know if an EKG was done in ER or not. Not done after she came to me.
  11. Visit  Medic09 profile page
    1
    Quote from medicrn13
    [URL]
    She doesn't really present with all the classic signs/symptoms of sepsis (fever or low temp, tachycardia, tachypnea...) Really just that pesky blood pressure, white count and lactic acid level.
    Just a side point. I mildly disagree with this statement. Those factors alone are enough to initiate a protocoled sepsis screening in many EDs, including ours. Also, the RR 20 would be borderline in such a case, not ignored. And the PMHx would be a factor, too.

    Of course, medicine isn't a cookbook discipline. That's why the doc didn't Dx sepsis in the end. But this patient would certainly have had my alarm bells going for sepsis 'till proven otherwise. All that was missing here was something like 'elderly' and 'diff. urinating', or 'altered mental status'.
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  12. Visit  Turtle in scrubs profile page
    0
    We have a sepsis screening tool. She was positive for SIRS but because she didn't have a known/suspected infection and wasn't on an antibiotic. Therefore on paper it didn't go any further... but paper has it's limits. Not to mention we didn't look very hard to see if there was an infection. With a LA of 3.2 I thought I would bounce it off of you fine folks
  13. Visit  meandragonbrett profile page
    0
    Was your patient receiving LR as IVF?

    WBC of 19 doesn't really tell us anything. What we need to know is the diff on the WBC.


    Lactate was probably slightly elevated secondary to the hypotension and anaerobic metabolism that results.
  14. Visit  Turtle in scrubs profile page
    0
    Quote from meandragonbrett
    Was your patient receiving LR as IVF?

    WBC of 19 doesn't really tell us anything. What we need to know is the diff on the WBC.


    Lactate was probably slightly elevated secondary to the hypotension and anaerobic metabolism that results.

    Not sure how much fluid she got initially. I picked her up a day later and she was on 75 cc NS/hr, that was turned off probably after she was there 24 hours and a day before she went home.

    So the diff would tell us likely reasons for the elevation in WBC, and I haven't been paying attention to the diff... looks like this is an area for improvement.

    So if it were infection we would be looking for an elevation in neutrophils, lymphocytes, or monocytes... sound right? What about a stress reaction .. what would be elevated then?


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