A "hypothetical case". Seeking wisdom

[EMEDPA]

80 yr old male with c/c of "Don't feel good and swelling all over" x 1 week.  high lactate (say 4.0), no fever, and no obvious source of infection. No abd pain or diarrhea, so ischemic colitis less likely. Significant new peripheral edema( 3+ b/l to mid-thighs). BNP 15,000. Cxr nl and minimal crackles b/l bases. Mild sob with nl vbg and covid neg. Nl sao2. Nl dimer. Nl lytes. bun/cr ratio 30 ( say 30 to 1.0) with concentrated urine. Lab evaluation indicates both volume depletion/poor perfusion and volume excess. pt not tachycardic and has a nl bp.  On low dose lasix ( 20 mg/day) from pcp for mild chf with EF 65% on recent echo. 

do you:

A: fluid bolus and abx for poor perfusion and/or sepsis without source

B: diurese for volume excess

C : Both

D : Neither (something else). 

[MediMike]

46 minutes ago, EMEDPA said:

80 yr old male with c/c of "Don't feel good and swelling all over" x 1 week.  high lactate (say 4.0), no fever, and no obvious source of infection. No abd pain or diarrhea, so ischemic colitis less likely. Significant new peripheral edema( 3+ b/l to mid-thighs). BNP 15,000. Cxr nl and minimal crackles b/l bases. Mild sob with nl vbg and covid neg. Nl sao2. Nl dimer. Nl lytes. bun/cr ratio 30 ( say 30 to 1.0) with concentrated urine. Lab evaluation indicates both volume depletion/poor perfusion and volume excess. pt not tachycardic and has a nl bp.  On low dose lasix ( 20 mg/day) from pcp for mild chf with EF 65% on recent echo. 

do you:

A: fluid bolus and abx for poor perfusion and/or sepsis without source

B: diurese for volume excess

C : Both

D : Neither (something else). 

Weird case. Hemodynamics were fine I'm assuming as you didn't mention them. I'm pretty worried about his RV, that combination of a clear CXR and new pitting edema to mid thigh puts that first and foremost in my mind.

I'd throw a probe on his chest personally. Check biventricular function, IVC. 

Also check a urine protein (silly in the ED I know) thinking about nephrotic syndrome. That's just pretty amazing edema to develop suddenly. Any other meds? Metformin? Check some LFTs...any herbals? Gimme a procal.

I'd definitely hold off on fluids, not sure what abx you'd want to start as I have no idea what we'd be covering for but could stick him on something to get him upstairs.

[EMEDPA]

I was also at a loss. Hospitalist had me bolus fluids at 30 cc/kg for poor perfusion as evidenced by the high lactate and give rocephin pending blood and urine cultures. The next day lactate normalized and edema and bnp worsened. He thought the edema might be due to a nutritional issue as albumin was low, but not ridiculously low. I will check on pt again today and see what else has been done or discovered. 

[EMEDPA]

Just discharged with a dx of " edema due to protein calorie malnutrition". 

[MediMike]

16 minutes ago, EMEDPA said:

Just discharged with a dx of " edema due to protein calorie malnutrition". 

Bold move.

Outside of kwashiorkor I'm not convinced I've seen actual hypoalbuminemia induced edema in a chronic process like poor nutrition. The issue is as you lose intravascular albumin you also lose the extravascular albumin and end up net even effectively...now when you acute massive losses like nephrotic syndrome or an enteropathy it's a little different due to the rapidity of the loss.

Not having seen their workup I'm not saying they are wrong...but how was the rest of the liver? Major lactate clearer of course...

How low was the albumin? 

[EMEDPA]

total protein 4.6

alb 2.1

ast, alt, T. Billi all nl

INR 1.4

[MediMike]

Yeah that doesn't add up to me. Wouldn't be surprised if he/she bounces back at some point.

You don't (in my experience) develop 3+ pitting edema to the mid-thigh with an albumin of 2.1. I want a RUQUS and a TTE please.

[EMEDPA]

13 minutes ago, MediMike said:

Yeah that doesn't add up to me. Wouldn't be surprised if he/she bounces back at some point.

You don't (in my experience) develop 3+ pitting edema to the mid-thigh with an albumin of 2.1. I want a RUQUS and a TTE please.

will keep that in mind if I see them again, thanks!

[GetMeOuttaThisMess]

Retired Clint Eastwood here, literally sitting on enclosed patio. It would be interesting to note if students, or recent grads, understand the relevance of the INR and albumin levels, and what specific question the two values answer in day today’s clinical settings?  Should be relatively simple, but based on a group of other tests and how they are referenced in day-to-day activities, it may not be so clear to some. By the way, please stay off my yard, especially since I just had fertilizer sprayed. I need to consider getting a Clint Eastwood sponsored cooler for my patio.

[polarbebe]

On 10/17/2021 at 5:14 PM, EMEDPA said:

80 yr old male with c/c of "Don't feel good and swelling all over" x 1 week.  high lactate (say 4.0), no fever, and no obvious source of infection. No abd pain or diarrhea, so ischemic colitis less likely. Significant new peripheral edema( 3+ b/l to mid-thighs). BNP 15,000. Cxr nl and minimal crackles b/l bases. Mild sob with nl vbg and covid neg. Nl sao2. Nl dimer. Nl lytes. bun/cr ratio 30 ( say 30 to 1.0) with concentrated urine. Lab evaluation indicates both volume depletion/poor perfusion and volume excess. pt not tachycardic and has a nl bp.  On low dose lasix ( 20 mg/day) from pcp for mild chf with EF 65% on recent echo. 

do you:

A: fluid bolus and abx for poor perfusion and/or sepsis without source

B: diurese for volume excess

C : Both

D : Neither (something else). 

Agree with above, POCUS to assess right sided heart function (short axis D-sign and comparing ventricle sizes).  ECG show anything interesting?  S1Q3T3, new right axis deviation or right bundle branch block?

Clearly hypervolemia as evidenced by the 3+ pitting edema.  The high BUN/CR ratio is pre-renal; pre-renal is either hypovolemia (which this patient clearly is not) or poor forward flow; disagree with giving additional fluids.  Hypoalbuminemia causing low intravascular volume (thus low preload, low stroke volume and then low CO) from low oncotic pressure can be a contributing factor but not the main reason given the albumin is only 2.1.

The lactate is elevated from poor forward flow (decreased cardiac output).  The INR is elevated (either for poor nutrition - lack of green healthy vegetables, recent abx use, sepsis) likely due to hepatic congestion.  Also the liver is responsible for about ~70% of lactate clearance (kidneys 5%, muscle 20%).  So two reasons for elevated lactate - poor forward flow (compensated with normal BP) and poor clearance of the lactate.

The rales and SOB can be due right heart dysfunction.  Is the patient obese?  Undiagnosed OSA/OHS, smoker, chronic VTE disease?  Especially given the low edema, he could have multiple chronic PEs (which do not have any tachycardia, normal dimer, etc.).  

However, most likely the right heart is overloaded, pushing the intraventricular septum into the left ventricle partially blocking the left outflow tract which causes backup into the lungs (EF can still be 65% and have pulmonary edema).  Also this can cause some element of diastolic dysfunction in the LV as the intraventricular septum is less compliant, partially contributing to decreased preload - again more backup in to the lungs.  

I would give lasix (and consider albumin before lasix - though not evidence based).  I would hold off on anti-microbials, pan-culture this patient and send a procal (know this has a low sensitivity and should not be used to screen sepsis).  I would check b/l LE duplex.

 

Edited October 19, 2021 by polarbebe

[LT_Oneal_PAC]

I’m betting this is a cardiac issue. Would agree with cardiac POCUS, specifically looking at EPSS, and I bet you would see some B lines on lung US even in normal CXR as US is more sensitive. All those issues can be caused by decreased perfusion and lack of forward flow. 
 

I would have given small dose of lasix and reevaluate. 
 

 

[ChrisPAinED]

On 10/17/2021 at 5:14 PM, EMEDPA said:

80 yr old male with c/c of "Don't feel good and swelling all over" x 1 week.  high lactate (say 4.0), no fever, and no obvious source of infection. No abd pain or diarrhea, so ischemic colitis less likely. Significant new peripheral edema( 3+ b/l to mid-thighs). BNP 15,000. Cxr nl and minimal crackles b/l bases. Mild sob with nl vbg and covid neg. Nl sao2. Nl dimer. Nl lytes. bun/cr ratio 30 ( say 30 to 1.0) with concentrated urine. Lab evaluation indicates both volume depletion/poor perfusion and volume excess. pt not tachycardic and has a nl bp.  On low dose lasix ( 20 mg/day) from pcp for mild chf with EF 65% on recent echo. 

do you:

A: fluid bolus and abx for poor perfusion and/or sepsis without source

B: diurese for volume excess

C : Both

D : Neither (something else). 

Sorry for bringing back this case but I am very interested in it. So edema in legs, mild crackling heard, and heart failure so a bit sketch of minor pulmonary Edema and wouldn't want to give fluids if possible. I would repeat labs watch BP and do a pocus to access the enthusiasm of the valves and access the hearts ability to beat. Maybe also do a renal workup as well. Also maybe increase diuretic. If pocus doesn't show the heart is very energetic and happy maybe admit for monitoring. If BP drops or labs show a similar result then fluids but try not to.