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?
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