A 65 year old man is brought to your Emergency Department by ambulance following several brown vomits.
On examination – jaundice, tachypnoea
BP 95/55, PR 120/min
Abd – soft and non tender
Describe and Interpret
pH 7.10 (7.36-7.44) Na 130 (137-145)
CO2 15 (35-45) K 4.2 (3.3-5)
HCO3 5 (24) Cl 90 (99-111)
HB 60 (>110) Glucose 40 (4-6)
WCC 22 (4-11) Urea 22 (3-7)
Creat 245 (<130) Lactate 18 (<2)
Great case !!
Life threatening, primary metabolic acidosis [HAGMA, elevated lactate & urea + hyperglycaemia ?ketones] with maximal respiratory compensation.
– marked anaemia ?acute GI bleed + decompensated liver failure + AKI
– marked lactaemia = ?sepsis/haemorrhage with hypoperfusion, ??toxic alcohol
– associated ?DKA/HUS.
1* metabolic acidosis.
– exp CO2 = (1.5 x 5) + 8 = 15.5, therefore maximal resp. compensation !
– Anion Gap = 130 – (5 + 90) = 35, therefore HAGMA (marked lactaemia & elevated uraemia are likely causes, however severe hyperglycaemia raises possibility of ketoacidosis as contributor)
– Delta ratio = (35 -12) / (24 – 5) = 23/19 = 1.2, therefore pure HAGMA.
Hyperosmolar.
– calc Osmol: (2×130) + 22 + 40 + ?alcohol = 322 [?DKA vs HHS]
Severe anaemia.
– Hb 60. ?acute GIT loss (varices vs PUD), likely coagulopathy
Elevated urea & creatinine.
– likely acute, given clinical context (hypoperfusion +/- volume depletion)
– Ur:Cr > 1, ?urea 2* GI bleed.
Normokalaemia.
– 4.2 in setting of severe acidosis likely represents whole body depletion ! Caution with correction of acidosis. Consider replacement.
Great comment Chris, as you know the high lactate is associated with high mortality >90%.