80 year old man with altered mental state and shock requiring urgent resuscitation

metabolic acidosis

high anion gap

delta ratio = 1, pure HAGMA

compensated, expected CO2 is 34, actual is 34.8

Severe hypernatraemia, with relative pseudohyponatremia (the measured Na is actually lower than the actual Na), actual Na = glu-10/3 + Na = 169

osmolality = >320 => hyperosmolar, expect Urea to be very high

severe hyperlactataemia

mild hyperkalaemia

Elevated chloride and glucose

renal failure

HCO3 >15

Osmolality >320

Glucose 36

likely to reflect HHS

Severe volume depletion

Look for cause of HAGMA and /or cause of HHS

Treatment:

assess A/B

VOLUME  VOLUME   VOLUME  – up to 10 litres deficit can occur in these patients

Treat cause

monitor electrolytes

Insulin not usually required (at least not in large doses as fluid alone will often correct the hyperglycaemia)

HDU/ICU admission