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:
- Describe and Interpret the bloods
- What is MELAS?
- What are your treatment priorities?
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
Excellent interpretation
Check out the answer for some info on MELAS.
Oh I just found your answer above. Thanks for these cases by the way they’re great.
Glad you are enjoying them. They are all actual patients that come through our ED