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 - 8
Mar -
Normal gap acidosis from diarrhea
17 Dec2009
Yesterday I provided this patient:
Interesting patient presented recently. He is HIV+ and has a 10 day history of large volume watery diarrhea. On the 3rd day his BMP showed. On admission his HCO3 was 19.
| Electrolyte panel | |||||
|---|---|---|---|---|---|
| Na | 149 | Cl | 128 | BUN | 13 |
| K | 3.0 | HCO3 | 12 | creat | 0.8 |
This is actually relatively easy.
1. What is the likely acid-base problem?
Given the large volume watery diarrhea, he likely has stool losses of bicarbonate.
2. How can we prove our assumption?
We obtained an ABG and a urine anion gap.
ABG: pH 7.2; pCO2 23; pO2 125; HCO3 9
Una 58; Uk 11; Ucl 156 – for Urine Anion Gap of -87. This is a profound negative anion gap and confirms our suspected diagnosis.
3. How would you treat this patient?
We considered 3 issues in treatment:
- Hypernatremia – patient had a free water deficit
- Metabolic acidosis – given the profound bicarbonate loss we had to give bicarbonate
- Hypokalemia – need to replete
We gave D5/W plus 2 amps of bicarbonate for 2 days and corrected the acidosis. The serum sodium decreased with the extra free water.
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This is not a tricky problem, but one that I rarely see. Developing a normal gap acidosis from diarrhea requires very large volume diarrhea. This patient had that problem secondary to MAC colon infection (diagnosis made on the first day).
Related posts:
- A normal gap acidosis dissected
- My thoughts on March 8 acid-base
- Part 2 of the acid-base problem
- 15 days at the VA – day 2
- 15 days at the VA – day 3
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3 Responses to Normal gap acidosis from diarrhea
ram
December 18th, 2009 at 7:20 am
How much D5/W was given?
How to calculate dosage of bicarb?
ram
December 18th, 2009 at 8:16 am
What if patient is diabetic?
Is it advisable to give D5/W and ad insulin in IV fluid to control sugar in diabetics?
Snipergirl
January 17th, 2010 at 1:35 am
@Ram, there are formulas to calculate free water deficit- here is one: http://www.mdcalc.com/free-water-deficit-in-hypernatremia
If high blood glucose is a problem, an insulin infusion can be run concurrently – both for the hyperglycaemia and also to prevent nephrogenic DI due to the hyperglycaemia