Favorite Quotes
"For every complex problem, there is a solution that is simple, neat, and wrong." - HL Mencken
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"I hear and I forget. I see and I remember. I do and I understand." - Confucius
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"The good physician treats the disease; the great physician treats the patient who has the disease" - Sir William Osler
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" The best test of a person's character is how he or she treats those with less power." - Bob Sutton
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"Those are my principles, and if you don't like them - well, I have others." - Groucho Marx
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"The difference between genius and stupidity is that genius has its limits." - Albert Einstein
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"It is hard enough to remember my opinions, without also remembering my reasons for them" - Friedrich Nietzsche
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"Anyone can make the simple complicated. Creativity is making the complicated simple." - Charles Mingus
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"Not everything that can be counted counts, and not everything that counts can be counted." - Albert Einstein
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"A foolish consistency is the hobgoblin of little minds, adored by little statesman and philosophers and divines. With consistency a great soul has simply nothing to do." - Ralph Waldo Emerson
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"This ain't no party, this ain't no disco, this ain't no fooling around." - Talking Heads, Life During Wartime
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"What is hateful to you, do not do to your neighbour. This is the whole Torah; all the rest is commentary. Go and learn it." - Hillel, Talmud, Shabbath 31a
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"You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing." - Thomas Sowell
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"An idealist is one who, on noticing that a rose smells better than a cabbage, concludes that it will also make better soup." - HL Mencken
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"If you only have a hammer, you tend to see every problem as a nail." - Abraham Maslow
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"A great teacher is one who realizes that he himself is also a student and whose goal is not to dictate the answers, but to stimulate his students creativity enough so that they go out and find the answers themselves." - Herbie Hancock
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"There are no facts, only interpretations." - Nietzsche
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"An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you do know and what you don't." - Anatole France
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"In character, in manner, in style, in all things, the supreme excellence is simplicity." - Henry Wadsworth Longfellow ====
Nov - 15
Dec - 19
Jan - 21
Feb - 7
Mar -
My answer to intubated
4 Jun2009
To remind readers
| ABG | |
|---|---|
| pH | 7.48 |
| pCO2 | 50 |
| pO2 | 96 |
On a respirator
Making rounds yesterday in the ICU, we found this electrolyte panel
| Electrolyte panel | |||||
|---|---|---|---|---|---|
| Na | 138 | Cl | 97 | BUN | 32 |
| K | 3.6 | HCO3 | 36 | creat | 1.1 |
| Blood Sugar | 165 |
As usual, figure out the acid-base disorder and explain the sequence of events. The patient has been intubated for 3 days. He has COPD and CHF.
His ABG from 3 days previously –
| ABG | |
|---|---|
| pH | 7.36 |
| pCO2 | 57 |
| pO2 | 115 |
There are two likely possibilities here, and they are not mutually exclusive. One strong possibility is the entity known as "revealed" metabolic alkalosis. This occurs when a patient has respiratory acidosis and appropriate metabolic compensation. The patient is on a respirator and ventilation improves, decreasing the pCO2, revealing the metabolic compensation.
The patient also was heavily diuresed for CHF (IV Lasix drip) which probably led to some volume contraction (note the high BUN/Cr).
With these ABGs I too (a bright commenter suggested this) ordered acetazolamide 250 mg IV for 2 doses. This lowered the bicarbonate level to 34 and the patient was successfully extubated.
Did the acetazolamide make the difference? I do not know for certain, but I have used it periodically over the past 30 years, and have read articles supporting this concept. Clearly metabolic alkalosis provides and inhibition to ventilation, and thus is undesirable.
I will admit that the data are unclear here, but the acid-base analysis is correct.
Related posts:
- Acid base answer
- ABG dilemma discussed
- Intubated and difficult to wean
- My thoughts on March 8 acid-base
- AMS – an acid-base problem II
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