A 66 year old patient presents feeling unwell for 2 days. She has chronic renal failure and is on haemodialysis once a week. Her last dialysis was 3 days ago when 1.5 litres was removed (normal for patient). She has not had excessive weight gain over the last few days.
T 35 degrees celcius
Her ABG shows on 10 litres shows:
pH 7.014 (7.36-7.44)
pCO2 39.2 (35-45)
pO2 123 mmHg
HCO3 9.5 mmol/l (22-26)
Hb 113 g/l (130-150)
Na 133 mmol/l (137-145)
K 4.0 mmol/l (3.5-5)
Cl 96 mmol/l (99-111)
Glucose 4.6 mmol/l (4-6)
Lactate 0.4 mmol/l (<2)
Creat 865 umol/l (<130)
Describe and interpret
What will the focus of your assessment be?
What are the indications for urgent dialysis?
metabolic HAGMA / failure of compensation (exp pCO2 23 – so relative resp acidosis coexisting) / delta ratio 1 (pure HAGMA)
normal lactate and glucose – effecitvyl excluding lactic acidosis and ketoacidosis.
renal acids most likely cause (toxic ingestion eg methanol can go on ddx but little evidence to suggest this)
note shock clinically with hypotensino
note also large a-A gradient
indications dialysis – hyperkalemia (not here), refractory acidosis (esp lactate but here alternative cause), toxicity from eligible drug.
assessment will look for cause of shock / sepsis / Aa gradient – eg sepsis, renal artery stenosis, PE,
Good answer. Remember to look for complications of chronic renal failure