Unwell patient with weakness presents with:
Compensated anion gap metabolic acidosis (AG 34)
Additional metabolic alkalosis (Delta gap >2)
Evidence of infection
elevated lactate – hypoperfusion, shock
Starvation causing ketosis and hypoglycaemia
Gastroenteritis – vomiting with loss of HCl
Causes of AG in this patient include renal failure, starvation ketoacidosis, sepsis, high lactate
Management of this patient includes fluid therapy, correcting hypoglycaemia in the first instance and then Insulin/dextrose infusion until ketosis resolves. Care must be taken to avoid further hypoglycaemia.
Identify source of sepsis and treat – possible GI in this patient, consider General Surgical review.
Treatment of ketoacidosis should aim for the following:
Reversal of the acidosis and ketosis
Reduction in the plasma glucose concentration to normal
Replenishment of electrolyte and volume losses
Identification the underlying cause