Critically unwell patient with
1. shock – hypotensive, tachycardic, hypothermia
2. life threatening acidaemia and lactic acidosis
He requires immediate fluid resuscitation and investigation for causes. Will need HDU/ICU admission
pH 6.91 severe acidaemia
HCO3 7.2, BE -24.5 severe metabolic acidosis
Anion gap 31 severe high anion gap metabolic acidosis (HAGMA)
Causes – sepsis, renal failure, ketones, toxins
Compensation using Winter’s formula: expected CO2 18, actual is 36
therefore uncompensated and likely additional respiratory acidosis due to prolonged hypoventilation (loss of consciousness, seizure, other)
Delta ratio 19/17 = 1, pure HAGMA
Unable to comment on Aa gradient on venous gas
High lactate (life threatening) – severe shock, sepsis, seizure, toxins
Normal glucose – urine showed 2+ ketones – alcoholic ketoacidosis, starvation ketoacidosis
Urea 8, Creat 120 – mild renal failure, dehydration, fluid depletion
high WCC/N – sepsis (backpain – ?diskitis)
Hb 171 – polycythaemia, dehydration
Osmolality 308 – high – dehydration
mild elevation in Na – dehydration
Normal K – however due to severe acidosis the total body K is likely to be depleted. Monitor K and replace as required
Normal Cl
Interpretation-
60 year old male with severe life threatening HAGMA and respiratory acidosis
Causes in this patient are multifactorial and may include:
1. seizure – hypoglycaemia, alcohol withdrawal, epilepsy
2. dehydration, shock
3. alcoholic/ starvation ketoacidosis
4. sepsis -?discitis, other (CXR was normal and UA only ketones)
5. Bleeding – GI (oesophageal varices, PUD) – PR was normal
6. Abdominal – pancreatitis (lipase was normal), gastritis, liver failure (LFT actually better than previous results, INR 1.3), abdominal catastrophy
7. Toxins – esp toxic alcohols (require osmolar gap). This patient did not present clinically as a toxic alcohol ingestion. His family were confident that this was not possible.
His blood alcohol level was 0
8. Respiratory acidosis – see earlier
So, what did we do?
1. managed in resuscitation bay
2. full non invasive monitoring
3. 2 large ivi cannulas
4. fluid resuscitation – initial fluid 0.9% saline
5. antiemetics
6. analgesia – paracetamol, pantoprazole
7. antibiotics – Tazocin 4.5grams
What about the severe acidosis?
We used isotonic HCO3 – 150mls of 8.4% HCO3 in 850mls of water/5% dextrose. Initially 250mls per hour over two hours, then 100mls/hr. When he finally went to ICU his pH was 7.27, HCO3 16, lactate 14, BP 120/60, PR 110/min. GCS was 15. Passed 100mls urine. Abdominal pain completely settled.