a doozy of an acid base problem

[deleted52758]

37 yo with upper GI bleeding, black colored emesis x 2 days. h/o of EtOH in past, last drink four days ago

electrolytes:

Na 122, K 2.4 Cl 53 HCO3 37 BUN 26, Cr 1.2 Glucose:219
AGap: 32
pH 7.586, PCO2 of 50

serum osmol: 255.

my interpretation: i thought it was a triple acid base disturbance, a primary metabolic alkalosis, with a wide anion gap metabolic acidosis, and a respiratory acidosis. my senior residents didnt want to work up the wide anion gap by doing other toxic alcohols because they said it was a primary metabolic alkalosis.

what do you guys think?

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[bulgethetwine]

37 yo with upper GI bleeding, black colored emesis x 2 days. h/o of EtOH in past, last drink four days ago

electrolytes:

Na 122, K 2.4 Cl 53 HCO3 37 BUN 26, Cr 1.2 Glucose:219
AGap: 32
pH 7.586, PCO2 of 50

serum osmol: 255.

my interpretation: i thought it was a triple acid base disturbance, a primary metabolic alkalosis, with a wide anion gap metabolic acidosis, and a respiratory acidosis. my senior residents didnt want to work up the wide anion gap by doing other toxic alcohols because they said it was a primary metabolic alkalosis.

what do you guys think?

Ah. Now we're talking interesting! I'll get back to this later as I'm in f*%$ing clinic.

Where's KGunner? Time for some physicochemical speak, me thinks!

 

[deleted52758]

if there was one thing i learned as an intern, is to never dismess metabolic acidosis, especially anion gaps... so i felt uncomfortable not working it up further.

 

[BlueFalcon]

maybe a silly question, but were the electrolytes and the ABG drawn at the same time?

 

[deleted52758]

yes.

 

[BKN]

37 yo with upper GI bleeding, black colored emesis x 2 days. h/o of EtOH in past, last drink four days ago

electrolytes:

Na 122, K 2.4 Cl 53 HCO3 37 BUN 26, Cr 1.2 Glucose:219
AGap: 32
pH 7.586, PCO2 of 50

serum osmol: 255.

my interpretation: i thought it was a triple acid base disturbance, a primary metabolic alkalosis, with a wide anion gap metabolic acidosis, and a respiratory acidosis. my senior residents didnt want to work up the wide anion gap by doing other toxic alcohols because they said it was a primary metabolic alkalosis.

what do you guys think?

I think he's a very sick guy. I tend to agree with your seniors:

Primary metabolic alkalosis from vomiting HCL from his stomach for a long time. Secondary resp acidosis to partially compensate. If he had a toxic alcohol I think he would have had an osmolal gap and his bicarb would have had a hard time getting to 37.

BTW is that a measured OG? I caclulate it as 265 using the standard formula, giving him a OG of -10

 

[DropkickMurphy]

maybe a silly question, but were the electrolytes and the ABG drawn at the same time?

The RT department at many places run the arterial samples for electrolytes as well (on the ABG analyzer), mainly for the purpose of the anion gap and for the R/O of life threatening 'lytes abnormalities in the ED and ICU.

 

[JkGrocerz]

I think he's a very sick guy. I tend to agree with your seniors:

Primary metabolic alkalosis from vomiting HCL from his stomach for a long time. Secondary resp alkalosis to partially compensate.

Wouldn't his compensation be a respiratory acidosis (hence his PCO2 of 50) if he was vomiting? Please point out if I'm missing somthing here

 

[BKN]

Wouldn't his compensation be a respiratory acidosis (hence his PCO2 of 50) if he was vomiting? Please point out if I'm missing somthing here

mybad, I got to thinking about something else while typing it. I've corrected my acid-base problem.

 

[ERMudPhud]

I'm not sure but I think you might also have confused your anion gap and your osmolal gap

 

[JackBauERfan]

I'm not sure but I think you might also have confused your anion gap and your osmolal gap

maybe bkn is having an alcohol related issue?

 

[beyond all hope]

If you have a high suspicion for a toxic alcohol on top, follow your gut. Lots of alcoholics will drink anything they can get their hands on. Besides, what better way to prevent an alcoholic from going into withdrawl? IV alcohol! Forget this fomizole stuff. EtOH is a lot cheaper.

Easiset and best way to find out if you have a toxic alcohol on board? Ask him. Most people will fess up to anything if you ask them the right way, unless they're truly nuts or completely obtunded.

Personally, I'd hydrate the heck out of this guy and recheck everything an hour or so later, and make sure it's not drawn from a line. That chemistry may have been drawn from a line spiked with fluids. I've had that problem. If ALL of the numbers on one lab are funky, think about lab error.

 

[BKN]

I'm not sure but I think you might also have confused your anion gap and your osmolal gap

OMG. Well you should have seen the calculations I was working on all day before that post. Faculty pay plan. It doesn't come more obscure than that.

 

[BKN]

maybe bkn is having an alcohol related issue?

No, but I'm about to have beer and pull out four hours of 24.

 

[JackBauERfan]

No, but I'm about to have beer and pull out four hours of 24.

woot, sounds like a great time to me! hmm reminds me about upcoming 24 season, too bad still have to wait a few more months haha.

 

[JustADoc]

Truly bizarre labs. Lowest Cl I've heard of.

You are right, it's a triple (MAlk, MAc, RAc).

The first thing I would do is to repeat the labs.

The huge AG should be worked up, but that's not as hard as people think. AG comes in two flavors: endogenous (uremia, ketones, lactate) and exogenous (toxins). Uremia is not the problem here, add on a ketones to the chemistries or better yet, check the U/A. Lactate is a separate tube of blood. If you're suspecting ingestion, add on a salicylate. Most patients with toxic alcohol ingestions will have an AG only (and no OG, people usually present when all the alcohols are metabolized away), but they will have some symptom (methanol gives eye findings, Et Glycol gives urine findings and sometimes hypoCa).

My guess: bogus labs or AKA / MAlk from vomiting / dehydration...

 

[bloredoc]

Wouldn't his compensation be a respiratory acidosis (hence his PCO2 of 50) if he was vomiting? Please point out if I'm missing somthing here