Lab case 78

A 64 year old female with MELAS presents with a 3 day history of vomiting and diarrhoea. She had been on an overseas holiday recently.

Vital signs:

BP  90/50

PR  120/min

RR  26/min

Temp  38 degrees celsius

Her blood results:

pH  6.92  (7.36-7.44)

pCO2    37   (35-45  mmHg)

HCO3   8   (22-26  mmol/l)

BE   -24

Na   129   (137-145  mmol/l)

K   >10.5  (3.5-5  mmol/l)

Cl   99   (99-111  mmol/l)

Glucose   4.8   (4-6)

Lactate    23  (<2 mmol/l)

Urea   16.1   (3-8  mmol/l)

Creat   159   (30-100  umol/l)

Trop   0.58  (<0.05)

Bilirubin  45  (<16  umol/l)

ALP   144  (30-115  umol/l)’

GGT  171   (<36  U/L)

ALT  25  (<36 U/L)

Lipase  52  (13-60  IU/L)

Questions:

  1. Describe and Interpret the bloods
  2. What is MELAS?
  3. What are your treatment priorities?

 

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4 thoughts on “Lab case 78

  1. 1. critical metabolic acidosis, Anion gap 22(HAGMA), Delta ratio 0.75 (slight coexisting NAGMA)
    expected pCO2 20 but it is actually 37: coexisting respiratory acidosis(failure of compensation
    life threatening hyperkalemia even allowing for pH-corrected normal of 7.4
    hyperbilirubinemia, obstructive LFT pattern.
    renal failure with high urea:Cr ratio (suggests pre renal)
    elevated troponin
    mild hyponatremia

    2. Pass – no idea what MELAS is

    3. Treatment priorities: Bolus saline 20mL/kg +/- repeat – aim to restore circ volume
    PPV to temporise acidosis …
    insulin 10U / glucose 50% 50 mL / Ca gluconate 10% 10mL
    [obtain ECG & if possible, echo]
    blood cultures and empiric antibiotics
    obtain specialist advice regarding “MELAS” – ?any specific therapy or missing metabolic substrate
    consider intubation and hyperventilation (with ventilation throughout induction) &/or haemofiltration if ongoing severe acidosis refractory to above

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    • Excellent interpretation
      Check out the answer for some info on MELAS.

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  2. Oh I just found your answer above. Thanks for these cases by the way they’re great.

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    • Glad you are enjoying them. They are all actual patients that come through our ED

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