Comments on: A 2 part acid-base problem

By: Blood Gasses Save Lives If You Know What To Look For - Better Health

Blood Gasses Save Lives If You Know What To Look For - Better Health — Wed, 30 Sep 2009 23:00:09 +0000

[...] in understanding. For me, their evaluation is mostly automatic. Some clinical scenarios are more complicated than others. But knowing your way through acid base will save lives your entire [...]

By: Happy Hospitalist

Happy Hospitalist — Fri, 28 Aug 2009 20:14:22 +0000

should say metabolic alkalosis from vomiting, not acidosis

By: Happy Hospitalist

Happy Hospitalist — Fri, 28 Aug 2009 20:13:43 +0000

She has a delta gap of 29. Which means her measured bicarb should by -5. Since its +7, she has a combined anion gap metabolic acidosis and a presumed alkalosis. Without blood gas it gets tricky. Should could possibly have a respiratory alkalosis as a compensation to the floating anion gap. She could also have a metabolic acidosis, say from vomiting.

Review MUDPILES. Consider the toxic alcohols. Check the urine for crystals. Certainly she could be a type one diabetic as well and perhaps overdosed on her insulin. Ketones, acetone.

Albumin of 4.9 in an alcohol with coagulatopathy would be highly unusual, unless profound dehydration. Which could account for the alkalosis. Although the BUN and Cr may be low because of malnutrition.

I would start D5NS infusion and, would even consider antedote for toxic alcohol while you wait for the levels to come back.

By: Clinton

Clinton — Wed, 26 Aug 2009 21:10:30 +0000

1) Acidemia
2) Metabolic acidosis(HCO3 <24)
3) Anion gap is 137-96 = 41
4) combined? delta-delta is (41-10)/(24-7) = 31/17 = 1.8 so most likely a pure AGMA.
5) is there an OSMOLAR GAP?!?

the differential diagnosis of an AGMA is MUDPILECATS… although Dr. Topf of Precious Bodily Fluids prefers GOLDMARK.
http://www.pbfluids.com/2009/02/student-lecture-on-acid-base.html
Given the history, it is likely that alcohol consumption plays a role.

The osmolar gap, along with the levels of EtOH, ethylene glycol and methanol will help us determine the appropriate course of action. If it is an advanced case of ethylene glycol poisoning, a UA may show crystals. Green fluorescence of urine with UV light will also show antifreeze consumption.

D5 and thiamine should be administered along with the appropriate antidote::
methanol poisoning: ethanol
ethylene glycol poisoning: fomepizole
Consider gastric lavage, activated charcoal and dialysis prn.

By: Stephen Weis DO

Stephen Weis DO — Wed, 26 Aug 2009 20:29:16 +0000

Comment #2

you also kept back that she smelled of ketones

treatment is hydration with Dextrose and 0.9 NACL

By: Stephen Weis DO

Stephen Weis DO — Wed, 26 Aug 2009 20:28:32 +0000

you also kept back that she smelled of ketones

treatment is hydration with Dextrose and 0.9 NACL

By: Stephen Weis DO

Stephen Weis DO — Wed, 26 Aug 2009 20:24:53 +0000

Its alcoholic keoacidosis

you kept back that she has been throwing up