Question 1:
The most important abnormality is Hb of 55 g/L, this needs urgent attention and management.
PH = 7.363, this is within normal range, close to the acidotic side.
PCO2 = 30.3 mmHg, this is low. Low PCO2 causes respiratory alkalosis. Unlikely this will be the primary process as the PH we have is closer to the acidotic side.
HCO3 = 16.8 mmol/L. This can explain the PH we have. So, the primary process is metabolic acidosis.
Since we have metabolic acidosis, then we need to calculate the anion gap and the compensation.
AG = Na – (Cl + HCO3) = 124 – (91 + 16) = 17, So we have HAGMA.
Compensation (using Winter’s formula), that is expected CO2 = ( 1.5 x HCO3 +8) +/- 2. Accordingly expected PCO2 should be between 31 and 35. We have PCO2 of 30, So this patient has additional mild respiratory alkalosis.
Because we have HAGMA, then we need to calculate the anion gap, that is:
(AG-12 )/ (24-HCO3) = 5/7.2 = 0.69. Value between 0.4 and 0.8 means we have combined HAGMA and NAGMA.
Other abnormal findings:
Na = 124, this is moderate hyponatraemia. However, this patient’s BSL is 26 mmol/L. Corrected Na level = Measured Na + (Glucose – 5)/3 = 131, This will change the level to mild hyponatraemia.
Lactate = 8.6, severe (serious) hyperlactatemia.
This patient had GI bleed from bleeding peptic ulcer, her urea level was 24 mmol/L with normal creatinine.
She had HAGMA due to hyperlactatemia secondary to reduced tissue perfusion and tissue hypoxia. Associated with NAGMA and respiratory Alkalosis.
Question 2:
The principles of bleeding management:
- Correct haemodynamics and maintain tissue oxygenation/ perfusion.
- Find the bleeding source.
- Arrest the bleeding.
- Correct coagulopathy.
This patient needs urgent blood transfusion. Activate the Massive haemorrhage protocol Start with O-ve then give crossed matched blood. Target systolic blood pressure of 70 mmHg. Mildly hypotensive resuscitation elicited the best resuscitation results (1). Infuse blood at ratio of 2:1.
Monitor: PH, Lactate level, B.E, INR, PT, APTT, Platelets count, Ionised Ca and temperature.(Prevent the triad of death).
The bleeding source was bleeding peptic ulcer.
Arrest the bleeding in this case:
- Administer PPI.
- Then this patient will need Gastroscopy with intervention or embolisation of the bleeding vessel or surgical intervention. This patient need to be urgently transferred to a surgical theatre.
Regarding the hyperglycemia, The management will differ according to the ketones level. If ketones level are with in normal range then aggressive management is not required. However, if the level was higher than 3, then consider DKA and treat the patient with NS and IV insulin according to the institute guidelines.