A 29 year old female presents unwell with hypotension, tachycardia and tachypnoea.

Her blood results indicate:Severe metabolic acidosis

High anion gap acidosis with normal renal function, lactate but high glucose and ketones

maximal compensation

delta ratio of 0.65, which indicates an additional non anion gap metabolic acidosis, with elevated chloride

Management is aimed at fluid replacement – limit normal saline use as the chloride will exacerbate the acidosis

electrolyte monitoring and replacement

with investigation and treatment of cause of illness