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Lactated Ringers And Lactic Acidosis

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In this video blog, Dr. Andrew Shorr discusses a recent study published in the New England Journal of Medicine on intensive vs conventional glucose control in patients who are critically ill.

Clinical Use Of Lactate Monitoring In Critically Ill Patients

Bakker et al.; licensee Springer.2013 Increased blood lactate levels (hyperlactataemia) are common in critically ill patients. Although frequently used to diagnose inadequate tissue oxygenation, other processes not related to tissue oxygenation may increase lactate levels. Especially in critically ill patients, increased glycolysis may be an important cause of hyperlactataemia. Nevertheless, the presence of increased lactate levels has important implications for the morbidity and mortality of the hyperlactataemic patients. Although the term lactic acidosis is frequently used, a significant relationship between lactate and pH only exists at higher lactate levels. The term lactate associated acidosis is therefore more appropriate. Two recent studies have underscored the importance of monitoring lactate levels and adjust treatment to the change in lactate levels in early resuscitation. As lactate levels can be measured rapidly at the bedside from various sources, structured lactate measurements should be incorporated in resuscitation protocols. Lactate LevelTissue HypoxiaBlood Lactate LevelLactate ClearanceMicrocirculatory Perfusion Many variables measured in critically ill patients Continue reading >>

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  1. blurfocus

    Your first, best, and cheapest option is not to use them.
    Ketostix do not measure what many people expect that they do.
    Ketostix only measure excess levels of acetoacetate, which is not the type of ketones that correlate with nutritional ketosis.
    Ketostix may show negative ketones when your blood ketones are high and then may show positive ketones when your blood ketones are low.
    Misinterpretation of what they show is one of the most common unnecessary causes of keto anxiety and wasted time. You can be perfectly successful on a ketogenic or low-carb diet without ever measuring ketones.
    Many people are already overwhelmed with learning about keto diets. Adding another layer of unnecessary complexity doesn't help the matter. Often, people are most successful on keto when they treat it as a lifestyle and not a diet. Obsessively measuring ketones can be at odds with attempting to live a keto lifestyle.
    If you decide to use Ketostix anyway, please be kind to those who answer questions here by not submitting a question that begins with I know that Ketostix are unreliable, but ...
    If you consume few enough carbohydrates and avoid excessive intake of protein, you can trust that your liver will be producing ketones within a single day. That is how human metabolism works.
    If you consume too many carbs, you will be kicked out of ketosis temporarily. However, if you once again restrict carbs, you will go right back into ketosis within 24 hours. This is because the liver can store only 100 grams of glycogen. If you restrict carbs, the liver will run out of glycogen within a day and begin burning fat instead. The liver produces ketones as a side effect of burning fat.
    As an example of how Ketostix can be misleading, it is possible to eat a high-carbohydrate meal followed by a positive Ketostix result. You may think that you cheated the system, but you didn't. It takes time for excess ketones to appear in urine. Ketostix are showing you what happened in the past before you cheated.
    If you have the time and really want to know why Ketostix will not tell you much, read pages 164 and 165 of The Art and Science of Low Carbohydrate Living by Volek and Phinney. This is the section headed by Ketones: To Measure or Not.
    If you do not have this book, read this summary:
    http://ketopia.com/why-you-need-to-stop-worrying-about-the-color-of-your-ketostix/
    Ketostix were designed to help diabetics avoid ketoacidosis which is a dangerous condition involving very high blood sugar and very high serum ketones. If you have near normal blood sugar and serum ketone levels consistent with nutritional ketosis, you don't need to worry about this.
    Ketostix only measure excess levels of acetoacetate, which is not the type of ketones that correlate with nutritional ketosis.
    The ketones that correlate with nutritional ketosis are known as beta-hydroxybutyrate. This type can be measured only with a blood ketone meter.
    There is a built-in time lag. Ketostix are measuring what has happened in the past since it takes a while for the kidneys to produce urine.
    Exercise can influence how many excess ketones are excreted.
    You can be in nutritional ketosis even when Ketostix show no excess acetoacetate. In the keto-adapted state, very little acetoacetate ketones will be excreted in urine even though blood ketones may be high.
    Note that it takes a period of four to six weeks of being in ketosis every day in order to become keto-adapted. Someone who is keto-adapted has adapted to using fat as the primary fuel for muscles and various organs. The keto-adapted brain uses ketones in place of glucose for most of its energy needs. When keto-adapted, most acetoacetate is not excreted. Instead, muscles convert it to beta-hydroxybutyrate and return it to the blood for use by the brain.
    If after all of this, you still want to use Ketostix because you bought them and cannot bring yourself to throw them away or because they are comforting in some way, here is how they may be useful.
    When you are first starting a low-carb or keto diet and transitioning into ketosis from a moderate to high-carb diet, Ketostix will confirm that your body has in fact done what biology says that it must do. It will show that your liver has begun producing ketones.
    Once you are a few days into the diet, you can give them away to a keto newbie or toss them. Note that Ketostix will eventually expire, especially if you keep them in a moist environment like a bathroom.
    If you have a medical condition that makes monitoring blood ketone levels necessary or if you are a numbers geek with spending money, you may be interested in purchasing a ketone blood meter and test strips for measuring beta hydroxybutyrate in your blood. The test strips cost somewhere between $2 and $5 per strip.
    There are a few meters to choose from.
    Precision Xtra - https://www.abbottdiabetescare.com/products/patient/pxtra-overview.html
    Nova Max Plus - http://www.novacares.com/nova-max-plus/
    CardioChek Home - http://www.healthchecksystems.com/CardioChek.cfm#home
    Most use one of the first two listed (Precision Xtra or Nova Max Plus). Some say that the Precision Xtra is the more accurate of the two. I've found that readings from these two track fairly closely with each other. The Nova Max Plus has cheaper test strips.
    To detect nutritional ketosis, look for a reading between 0.5 and 5.0 mmol / liter. Some experts recommend aiming for a level of 1.0 to 5.0 mmol / liter.
    Another option is the Ketonix Sport breath meter. This meter measures acetate in the breath. It does not require test strips.
    Acetate forms when acetoacetate spontaneously breaks down to acetate. According to Volek and Phinney (page 165 of The Art and Science of Low Carbohydrate Living), it should be linearly correlated with blood ketones. In practice, it is not as accurate as the blood meters in part because it is difficult to breathe in the same way every time you test.
    Ketonix Sport (order direct from Sweden) - https://www.ketonix.com/index.php/product/sport
    Again, remember that you can be perfectly successful on a ketogenic or low-carb diet without ever measuring ketones whether in urine, blood, or breath.
    In the final analysis, ketone concentrations are what they are. Chasing ketone concentrations often becomes as unnecessary and distracting as Ketostix. Unless you are treating epilepsy, cancer, or other medical condition, the concentration of ketones do not matter too much. You can achieve weight loss and a sense of well-being even with lower levels of ketones.
    Focus on how you feel, not on the number. Use ketone meters for interest and experimentation, but don't let the results stress you out.
    tl;dr never, unless you have read and understood this post, yet still want to use them anyway
    [If anyone has any suggestions for improving this post or correcting misinformation, let me know. I'll correct this and re-post it once in a while]

  2. anbeav

    Hallelujah!!
    tl;dr never
    If you want to do it for experimentation, go for it but please spare the rest of us the unnecessary ketosis anxiety
    edits: In addition to false negatives, ketostix commonly show false positives as in when people eat a high carb meal and think they cheated biology. Also I might remove the bit about using ketostix to monitor keto-adaptation, just asking for more posts about the issue. Also I might emphasize that people seem to already be overwhelmed with keto when starting and adding another layer of unnecessary complexity doesn't help the matter. People always talk about lifestyle, live a lifestyle and IMO living a lifestyle certainly shouldn't have to include measuring. Lastly, ketone concentrations are what they are. If you want to measure with a blood or breath meter, they are what they are and chasing ketone concentrations often becomes as unnecessary as ketostix. Unless someone has a medical condition for which a particular concentration is required for management, focus on how you feel not the number. Use the meter for interest and experimentation, but don't let it stress you out.

  3. blurfocus

    Thanks. I have incorporated your feedback.

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In this video we discuss the progression of a systemic infection including systemic inflammatory response syndrome, sepsis, severe sepsis, septic shock and multi organ dysfunction syndrome.

In Sepsis, Fluid Choice Matters

You are at: Home Research In Sepsis, Fluid Choice Matters During a large-volume sepsis resuscitation, your choice of fluids specially which crystalloid solution could mean the difference between life, death and dialysis Included in the emergency physicians skill set is their ability to resuscitate critically ill patients; an example of this is the emergency department care of the septic patient. Given the general delay in translating medical knowledge to the bedside, its remarkable to see the vast change in the management of these patients since Dr. Rivers published his ground-breaking paper [ 1 ]. In a relatively short period of time, weve made aggressive fluid resuscitation and early antibiotics the standard of care and now focus our attention on improving other aspects of the resuscitation. Recent literature has studied goal MAP requirements [ 2 ], endpoints such as lactate clearance vs ScvO2 [ 3 ], and how best to evaluate volume responsiveness (IVC measurement [ 4 ], passive leg raise [ 5 ], carotid velocity time integral [ 6 ]). One element that has received far less attention is the type of fluid that is administered during the resuscitation. As it turns out, the type of fl Continue reading >>

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  1. kailey_elise

    I have a friend. I noticed while kissing him last night that, a few different times, I noticed a very distinctive acetone smell/taste on his breath.
    While most assuredly an alcoholic, he's never been one in a point of desperation to the point of, say, drinking IPA or something. He drinks beer, and only the same kind of beer (no mixing brands or anything).
    My (limited) research shows that acetone is a metabolic byproduct of drinking IPA (uh, meaning isopropyl alcohol, you know, rubbing alcohol - not a nice IPA beer, hahaha), but haven't really noticed anything about ethyl alcohol/ethanol & acetone production.
    Does anyone know anything about why this might be? He's not a huge guy, so it's good he sticks to beer, but can easily (& somewhat often does) get fucked up to the point of being incomprehensible.
    A potentially important point to note is that he is on some *serious* antibiotics. Like, some hardcore, there aren't things much stronger, antibiotics. He has some kind of bone infection or something that they're trying to keep under control with the meds for as long as they can. I don't know if something like that could be affecting the way he processes the alcohol?? Maybe?
    No known immune system issues (barring any that could come from the bone thingy & antibiotics). No other illicit drugs other than cannabis is being consumed, the only other drugs are the aforementioned ABs.
    I really like this guy, and it's worrisome to me to notice this (not to mention it kinda tastes weird, hahaha). I know alcohol isn't good for you, and as an alcoholic he probably has all kinds of liver damage (or will soon), but I'm just worried that there is *extra* damage being done, since he is burning off acetone when he's drinking.
    Thanks in advance for ANY help anyone can provide, even if it's just better search terms to try or other websites to read...ANYTHING would be helpful, please!!
    ~Kailey

  2. Down In Albion

    Interesting question, the thing that instantly sprung to mind when you mentioned the Acetone smell is Ketosis, which in case you didn't know is a process of the body when you starve it of carbs (like when you're on the atkins diet). It creates a sickly sweet solvent taste very similar to Acetone in my opinion.
    Alcohol contains sugar, and so carbs, but maybe if he has a low carb diet, combined with tolerance to huge amounts of sugar from daily binge drinking, that would possibly allow his body to be in a state of ketosis.
    It's a long shot but it's the only explanation I can think of other than it just being a direct effect of the antibiotics, many can do odd things like change the colour of your pee or sweat etc... so why not breath?
    I can't remember the name, but there's one antibiotic that makes your TEARS turn red lol. So I'd guess it's highly possible that one could alter a persons breath!
    DIA
    Edit: I need to learn to read things twice when I'm spun. The part about Acetone being a bi-product of IPA totally went in and out lol. I'll have a look, see if I find anything.
    More Editing:
    Ketone bodies
    From Wikipedia, the free encyclopedia
    Ketone bodies are three water-soluble compounds that are produced as by-products when fatty acids are broken down for energy in the liver and kidney. They are used as a source of energy in the heart and brain. In the brain, they are a vital source of energy during fasting. Although termed "bodies", they are dissolved substances, not particles.
    The three endogenous ketone bodies are acetone, acetoacetic acid, and beta-hydroxybutyric acid, although beta-hydroxybutyric acid is not technically a ketone but a carboxylic acid. Other ketone bodies such as beta-ketopentanoate and beta-hydroxypentanoate may be created as a result of the metabolism of synthetic triglycerides such as triheptanoin.
    Uses in the heart and brain
    Ketone bodies can be used for energy. Ketone bodies are transported from the liver to other tissues, where acetoacetate and beta-hydroxybutyrate can be reconverted to acetyl-CoA to produce energy, via the citric acid cycle.
    The heart gets little energy from ketone bodies except under special circumstances; it uses mainly fatty acids.
    The brain gets its energy from ketone bodies when glucose is less available (e.g., during fasting, strenuous exercise, low carbohydrate, ketogenic diet and in neonates). In the event of low blood glucose, most other tissues have additional energy sources besides ketone bodies (such as fatty acids), but the brain does not. After the diet has been changed to lower blood glucose for 3 days, the brain gets 25% of its energy from ketone bodies. After about 4 days, this goes up to 70% (during the initial stages the brain does not burn ketones, since they are an important substrate for lipid synthesis in the brain).
    Production
    Ketone bodies are produced from acetyl-CoA (see ketogenesis) mainly in the mitochondrial matrix of hepatocytes when carbohydrates are so scarce that energy must be obtained from breaking down fatty acids. Because of the high level of acetyl CoA present in the cell, the pyruvate dehydrogenase complex is inhibited, whereas pyruvate carboxylase becomes activated. Thus, the oxaloacetate produced will enter gluconeogenesis rather than the citric acid cycle, as the latter is also inhibited by the elevated level of NADH resulting from ß-oxidation of fatty acids. The excess acetyl-CoA is therefore rerouted to ketogenesis. Such a state in humans is referred to as the fasted state.
    Acetone is produced by spontaneous decarboxylation of acetoacetate, yielding levels of acetone much lower than those of other ketone bodies. Acetone cannot be converted back to acetyl-CoA, so it is excreted in the urine, or (as a consequence of its high vapor pressure) exhaled. Acetone is responsible for the characteristic "fruity" odor of the breath of persons in ketoacidosis.
    Click to expand... Down In Albion added 13 Minutes and 11 Seconds later...
    I guess you don't have too much to worry about (other than the obvious issues of alcoholism), as it's a naturally occurring thing.

  3. beentheredonethatagain

    maybe it was speed breath, you know it could seem like acetone and really be another chemical, just a thought ,

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Lactated ringers refers to intravenous fluid that is used to treat someone after trauma, blood loss, fluid loss or burn injury. Find out why normal saline can be preferable to lactated ringers, because lactated ringers creates an imbalance within electrolytes, with help from a licensed RN in this free video on IV fluids. Expert: Kayti Brosnan Bio: Kayti Brosnan has been a licensed RN in the state of Texas since 2003. Filmmaker: Todd Green

Fluid Management In Diabetic-acidosis—ringer's Lactate Versus Normal Saline: A Randomized Controlled Trial

Objective: To determine if Ringer's lactate is superior to 0.9% sodium chloride solution for resolution of acidosis in the management of diabetic ketoacidosis (DKA). Design: Parallel double blind randomized controlled trial. Methods: Patients presenting with DKA at Kalafong and Steve Biko Academic hospitals were recruited for inclusion in this study if they were >18 years of age, had a venous pH >6.9 and ≤7.2, a blood glucose of >13 mmol/l and had urine ketones of ≥2+. All patients had to be alert enough to give informed consent and should have received <1 l of resuscitation fluid prior to enrolment. Results: Fifty-seven patients were randomly allocated, 29 were allocated to receive 0.9% sodium chloride solution and 28 to receive Ringer's lactate (of which 27 were included in the analysis in each group). An adjusted Cox proportional hazards analysis was done to compare the time to normalization of pH between the 0.9% sodium chloride solution and Ringer's lactate groups. The hazard ratio (Ringer's compared with 0.9% sodium chloride solution) for time to venous pH normalization (pH = 7.32) was 1.863 (95% CI 0.937–3.705, P = 0.076). The median time to reach a pH of 7.32 for the Continue reading >>

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Popular Questions

  1. maxell

    I'm wondering how people are coping with the stinky smell of ketosis. I'm on a ketogenic low-carb diet -- usually 60g of net carbs or less. I've tested myself with ketostix several times and I can smell the rancid urine smell when I pee.
    The problem here is that my toilet doesn't seem to flush completely and the ketogenic smell stays in the bathroom and even leaks to the living room. My super came in to my apartment once and asked what that smell is, whether I'm flushing my toilet.
    I've been using Lysol before I leave to air out the bathroom but that doesn't seem to be enough. Now, I'm using air fresheners, fragrance refills, and toilet bowl cleaners but I can still smell it when I enter my apartment. Not as bad but the smell is unmistakable.
    How do people deal with this ketogenic smell? It's good that I'm ketogenic. But I can do without the smell.

  2. skunk

    my daily carbs is less than 20 grams, and the acetone in my breath is so strong, i swear i can knock out flies LOL
    Not just that, my sweat has a strange smell too.
    I guess we just have to get used to it?
    At least now i know how Paleolithic Cavemen used to smell like lol

  3. Matt51

    A healthy person on a ketogenic diet, should only be slightly in ketosis according to the keto-sticks. After a couple weeks in ketosis, you should not be having a problem with bad breath or urine. 60g carbs a day is more than enough one should be out of ketosis.
    My guess is you have some other problem. Taking an activated charcoal tablet a day should help with the odor.

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