Unwell patient with weakness presents with:

1.

Compensated anion gap metabolic acidosis (AG 34)

Additional metabolic alkalosis (Delta gap >2)

Hypoglycaemia

ketosis

renal failure

Evidence of infection

elevated lactate – hypoperfusion, shock

2/3.

Starvation causing ketosis and hypoglycaemia

Gastroenteritis – vomiting with loss of HCl

Causes of AG in this patient include renal failure, starvation ketoacidosis, sepsis, high lactate

Other:

Management of this patient includes fluid therapy, correcting hypoglycaemia in the first instance and then Insulin/dextrose infusion until ketosis resolves. Care must be taken to avoid further hypoglycaemia.

Identify source of sepsis and treat – possible GI in this patient, consider General Surgical review.

Treatment of ketoacidosis should aim for the following:

• Fluid resuscitation
• Reversal of the acidosis and ketosis
• Reduction in the plasma glucose concentration to normal
• Replenishment of electrolyte and volume losses
• Identification the underlying cause