Issues –

1. Critically unwell patient with shock requiring resuscitation

2. High glucose – HHS vs DKA

3. Severe Sepsis

4. Possible complications from high risk patient

pH 7.2, HCO3 15, BE -12 => moderate metabolic acidosis

high lacate – lactic acidois

high glucose – HHS (type 2 diabetic, no information on insulin use given) more likely than DKA ( ketones not given)

Anion gap = 14, upper limit of normal (normal anion gap acidosis is consistent with HHS, may have HAGMA due to lactate or other contributory cause)

Compensation: expected CO2 = 30.5, actual is 38 => poorly compensated / patient with COPD and CO2 retention.

Delta gap = 0.3 consistent with mixed anion gap and non anion gap acidosis

Osmolality = using corrected sodium = 329 consistent with HHS and severe dehydration [interestingly, the calculated lab osmolality was 334 :)]

Corrected sodium = 132 mild hyponatraemia

High WCC – sepsis, dehydration effect contributory

moderate to severe hyperkalaemia – true level lower due to acidosis, requires correction and monitoring.

Interpretation – 55 year old female, in shock requiring concurrent fluid resuscitation and investigation with mixed high anion gap and normal anion gap metabolic acidosis, severe hyperglycaemia and mild hyponatraemia. Her results are consistent with HHS and lactic acidosis. Early broad spectrum antibiotics are indicated. Consider HDU admission for ongoing care.

some other blood results:

ketones 0.3

ESR 130

CRP 287

Lipase 216

Troponin 7.44 (<0.05)

Hb 76 (115-155 g/l) – this was acute on chronic

Normal LFT

Criteria for HHS:

• Plasma glucose level of 30 mmol/L or greater
• Effective serum osmolality of 320 mOsm/kg or greater
• Profound dehydration, up to an average of 9L
• Serum pH greater than 7.30
• Bicarbonate concentration greater than 15 mEq/L
• Small ketonuria and absent-to-low ketonemia
• Some alteration in consciousness