Let me just preface this upfront.
I want to open a discussion about this, but as I am actively trying to get it published, I am not citing any sources here. That way you are at least 2 weeks behind me if you try to steal it.
For many years, the heart, brain, and kidney have been listed as the vital organs to save in an emergency.
I postulate in the long term, the liver is also key.
Recently the focus of my study was on the use of NGAL to detect AKI early enough to do something about it.
In trauma and conditions such as cardiac sugery and sepsis, renal function is impaired because of medulary sensitivity to decreased oxygen.
The current standards of creatine and bun do not reflect this injury for ~48 hours, and even then because of many variables it is difficult to interpret.
NGAL is both sensitive and specific (numbers withheld intentionally) but better than 80% according to most reputable studies, in as little as 2 hours. It is demonstrative not only of the injury, but also prognostic in many cases as well.
2 companies have already marketed easy and relatively inexpensive as far as medical equipment goes, point of care testing.
The point of early detection is to initiate therapies early enough to preserve as much renal function as possible.
But it got me wondering, which is why I am posting this.
Lactate has long been a gold standard of determining hypoperfusion in shock states. But it is a systemic measurement. It is not measuring how much the liver is converting back to pyruvate in compensation. It is not measuring damage to individual tissues. (Especially the kidney) Which might mean that even though lactate is normal. There may still be hypoperfusion to sensitive tissues like kidney and liver prolonging subclinical injury. (the 2 organs highly suseptable to slight changes in oxygenation due to the diffusion distances of their active tissues)
Now if you've spent anytime with the pathology of shock, you know that basically the body reaches the point of decompensation because it has used every mechanism available to it to maintain mostly perfusion to the brain and kidneys. Eventually even the heart cannot be perfused and the game is over.
Now keep in mind, I am talking about sick people, who will require timely intervention in order to break the cycle of progressive shock. Not the mild controlled blood loss, or slightly dehydrated.
So by using a global measure of shock, like lactate level, which incorperates every organ/tissue I wonder if we are underresuscitating, or not resuscitating when it may be beneficial.
Cardiac Troponin I is both fast and specific.
NGAL while not widely used, meets the same criteria for a more sensitive organ.
Brain I haven't thought of a marker yet.
There is a whole panel for liver function, and while not traditionally included in core circulation (my nobel in the making) it is the location of significant protein synthesis, the urea cycle, and metabolism.
While the liver is not part of the traditional "core" mostly from the thinking it has regenerative capacity long term. In the short term, the impairment of such can inhibit hemostasis, inhibit conversion of lactate, and inhibit the formation of urine which systemically inhibits a whole slew of metabolism as well as various electrolyte balances.
Doesn't that sound important? (rhetorical)
So here is the discussion part:
In the early stages of medical intervention, EMS and ED, is more tissue specific and aggresive resuscitation needed?
Is it practical?
Can it be made more/less so by POC diagnostics?
Could it improve quality of life 10 or even 20 years down the line because of early preservation of renal function which will be subject to the stress of chronic disease later?
Can early intervention prior to an ICU admit, or worse, no ICU admit, lead to decreased hospital stay and morbidity?
I have found no answers to these question, only expert opinion and theory. What is your take?
I want to open a discussion about this, but as I am actively trying to get it published, I am not citing any sources here. That way you are at least 2 weeks behind me if you try to steal it.
For many years, the heart, brain, and kidney have been listed as the vital organs to save in an emergency.
I postulate in the long term, the liver is also key.
Recently the focus of my study was on the use of NGAL to detect AKI early enough to do something about it.
In trauma and conditions such as cardiac sugery and sepsis, renal function is impaired because of medulary sensitivity to decreased oxygen.
The current standards of creatine and bun do not reflect this injury for ~48 hours, and even then because of many variables it is difficult to interpret.
NGAL is both sensitive and specific (numbers withheld intentionally) but better than 80% according to most reputable studies, in as little as 2 hours. It is demonstrative not only of the injury, but also prognostic in many cases as well.
2 companies have already marketed easy and relatively inexpensive as far as medical equipment goes, point of care testing.
The point of early detection is to initiate therapies early enough to preserve as much renal function as possible.
But it got me wondering, which is why I am posting this.
Lactate has long been a gold standard of determining hypoperfusion in shock states. But it is a systemic measurement. It is not measuring how much the liver is converting back to pyruvate in compensation. It is not measuring damage to individual tissues. (Especially the kidney) Which might mean that even though lactate is normal. There may still be hypoperfusion to sensitive tissues like kidney and liver prolonging subclinical injury. (the 2 organs highly suseptable to slight changes in oxygenation due to the diffusion distances of their active tissues)
Now if you've spent anytime with the pathology of shock, you know that basically the body reaches the point of decompensation because it has used every mechanism available to it to maintain mostly perfusion to the brain and kidneys. Eventually even the heart cannot be perfused and the game is over.
Now keep in mind, I am talking about sick people, who will require timely intervention in order to break the cycle of progressive shock. Not the mild controlled blood loss, or slightly dehydrated.
So by using a global measure of shock, like lactate level, which incorperates every organ/tissue I wonder if we are underresuscitating, or not resuscitating when it may be beneficial.
Cardiac Troponin I is both fast and specific.
NGAL while not widely used, meets the same criteria for a more sensitive organ.
Brain I haven't thought of a marker yet.
There is a whole panel for liver function, and while not traditionally included in core circulation (my nobel in the making) it is the location of significant protein synthesis, the urea cycle, and metabolism.
While the liver is not part of the traditional "core" mostly from the thinking it has regenerative capacity long term. In the short term, the impairment of such can inhibit hemostasis, inhibit conversion of lactate, and inhibit the formation of urine which systemically inhibits a whole slew of metabolism as well as various electrolyte balances.
Doesn't that sound important? (rhetorical)
So here is the discussion part:
In the early stages of medical intervention, EMS and ED, is more tissue specific and aggresive resuscitation needed?
Is it practical?
Can it be made more/less so by POC diagnostics?
Could it improve quality of life 10 or even 20 years down the line because of early preservation of renal function which will be subject to the stress of chronic disease later?
Can early intervention prior to an ICU admit, or worse, no ICU admit, lead to decreased hospital stay and morbidity?
I have found no answers to these question, only expert opinion and theory. What is your take?
