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AMS an acid-base problem – part 1
18 Jun2009
41 year old man with left hemipareis s/p right brain aneurysm surgery in the past. Now presents with increasing obtundation, increased urination and abdominal discomfort. Labs follow:
On 2l nasal oxygen:
| ABG | |
|---|---|
| pH | 7.41 |
| pCO2 | 47 |
| pO2 | 95 |
| Electrolyte panel | |||||
|---|---|---|---|---|---|
| Na | 128 | Cl | 83 | BUN | 8 |
| K | 4.2 | HCO3 | 24 | creat | 0.7 |
| Blood Sugar | 742 |
Now for the hard part, figure out the acid-base problem. Next I will give you his labs 2 days later, then my interpretation.
Related posts:
- AMS – an acid-base problem II
- March 8, 2010 – an acid base challenge
- A new acid-base problem
- A 2 part acid-base problem
- AMS – an acid-base problem solution
Related posts brought to you by Yet Another Related Posts Plugin.
5 Responses to AMS an acid-base problem – part 1
Phillip
June 18th, 2009 at 2:26 pm
At first glance, it looks like Hyperosmolar hyperglycemic nonketotic syndrome. Blook sugar is > 600, which is causing intravascular dilution of your NaCl. The corrected sodium for that level of hypoglycemia is 138, so it’s not true hyponatremia we’re seeing. There may be some CO2 retention secondary to his obtundation, but it’s probably being balanced out by bicard retention secondary to volume depletion. I’ll have a second look later once things settle down a little more around here.
Roger
June 18th, 2009 at 4:01 pm
This one seems like a tough one. First, looking directly at the ABG, it appears normal or very nearly normal. There is a slight elevation of CO2 and low normal pH, but it doesn’t reach a level that I would call respiratory acidosis. Whenever I see what appears to be a normal ABG I look a the anion gap. At first glance, the AG appears to be 19. Like the above poster, I agree that the hyponatremia is really secondary to hyperglycemia. However, are we supposed to use the corrected Na to calculate the AG? If so, then the AG is 29. Either way, we have a hidden anion-gap metabolic acidosis, in spite of a normal pH, suggesting a mixed disturbance with a metabolic alkalosis.
Obviously, the secret here is in the history and other labs, but I guess the fun is in venturing a guess. Here goes.
This gentleman has diabetic ketoacidosis, causing his abdominal discomfort, frequency, and obtundation. The acidosis is covered by his metabolic alkalosis. Has he been vomiting secondary to his abdominal discomfort? If so, maybe he has a metabolic alkalosis secondary to loss of HCl (apparent in his low serum Cl).
None of this really fits with the surgical history, which I’m sure is important. Does he also have primary HPA axis dysfunction? DI? I don’t know. I look forward to the labs and explanation.
Many thanks!
Neil
June 18th, 2009 at 7:53 pm
I think there are three abnormalities:
1) Metabolic ketoacidosis 2/2 DKA/HHS
2) Respiratory alkalosis 2/2 compensation/obtundation
3) Metabolic alkalosis 2/2….this is the tough one. It could be due to antacid intake for abd pain. Possibly vomiting though wasn’t in the history. Can’t profound total body potassium depletion over extended time cause a metabolic alkalosis??
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Snipergirl
January 17th, 2010 at 12:31 am
My guess is…
Firstly this man has a chronic hypercapnia due to perhaps hypoventilation in the setting of his old aneurysm. Thus he usually has chronic metabolic compensation also.
Now he goes into DKA which drops his CO2 into normal range (just) but also causes a profound drop in the HCO3 (which may normally be 37 or so) down to 24 as well as the ketone related anion gap of 20.