Acid-base disorders--- How to interpret?

[dreamer2012]

I always have problems interpreting the acid-base disorders. I have a case
below from a text book. Can somebody please discuss how to solve the
problems?
-----------------------------------------------------------------------
Case 1: A 50-year-old 70kg alcoholic man presents with 4 days of nausea,
vomiting,and mild abdominal pain following a week-long drinking binge. He is unable to take anything by mouth. His mucous membranes are dry, and his vital signs reveal an orthostatic blood pressure drop with a rise in pulse. The following laboratory data are obtained:
Na: 134 mEq/L
K : 3.1mEq/L
HCO3:20mEq/L
CL:80mEq/L
glucose:86 mg/dL
BUN:52 mg/dL
Cr: 1.4 mg/dL
serum ketones:high positive reading.

ABG:
pH: 7.32
Pco2 : 40mmHg
HCO3: 20mEq/L

Urine sodium: 7mEq/L(low)
Urine Ketones: high reading.

What is the diagnosis?

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[J-Rad]

This post is likely going to get shut down as a homework-help thread because basically you're asking everyone else to just answer the question for you. It might be more instructive and educational if you describe what you see in the scenario and where you come to mental roadblocks which the readership might help you overcome.

I think most people will be unwilling to just hand you the answer...you know the whole "teach a man to fish thing"...

So here's a fishing pole: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1002945/
This was the most singularly helpful thing I read to help me with acid base disorders (at least with a traditional non-Stewart understanding of them). The acid base stuff should become clear. There are other clues and diagnoses which should be obvious in the case.

 

[proman]

The answer: not sick enough for an ICU.

 

[Hernandez]

http://www.lakesidepress.com/ABGindex.htm

best book out there on acid-base

 

[dreamer2012]

Thanks Dr. J-RAD and Dr. Hernandez. I will study the material that you guys posted, and try to interpret it by myself first, and then, if there are something that I can't understand, I will ask for help.
Thanks again.

 

[edmadison]

The answer: not sick enough for an ICU.

I'd put him in the ICU. You're likely going to need to dialyze him. His acidosis will look much worse in several hours.

To the OP, all the clues you need are in the question.

Ed

 

[bulgethetwine]

I'd put him in the ICU. You're likely going to need to dialyze him. His acidosis will look much worse in several hours.

To the OP, all the clues you need are in the question.

Ed

Doubtful he would need ICU care unless you mismanage for those "several" hours.

 

[bulgethetwine]

This post is likely going to get shut down as a homework-help thread because basically you're asking everyone else to just answer the question for you. It might be more instructive and educational if you describe what you see in the scenario and where you come to mental roadblocks which the readership might help you overcome.

I think most people will be unwilling to just hand you the answer...you know the whole "teach a man to fish thing"...

So here's a fishing pole: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1002945/
This was the most singularly helpful thing I read to help me with acid base disorders (at least with a traditional non-Stewart understanding of them). The acid base stuff should become clear. There are other clues and diagnoses which should be obvious in the case.

Ditto on the Haber article. This should be re-published in a more mainstream journal.

 

[edmadison]

Doubtful he would need ICU care unless you mismanage for those "several" hours.

Nice.

Perhaps the admission criteria for adults are different than children. We might be able to avoid dialysis with timely treatment. However, if using either of the appropriate medical interventions (other than dialysis), a patient at my hospital would need to be in the PICU.

BTW to the OP, another hint: your patient's malady is seen most commonly in young children and sometimes their pets!

Ed

 

[J-Rad]

BTW to the OP, another hint: your patient's malady is seen most commonly in young children and sometimes their pets!

Ed

Actually, I would think this guy has a cousin of what you commonly see in children and pets. But a three year old coming in with this would have some serious other issues

 

[J-Rad]

OP:

I like and remember very few acronym mnemonics, but this is one I remember to help with some aspects of the problem:

M-
U-
D-
P-
I-
L-
E-
R-
S-

Can you fill it in (some have more than one)?

 

[jdh71]

Nice.

Perhaps the admission criteria for adults are different than children. We might be able to avoid dialysis with timely treatment. However, if using either of the appropriate medical interventions (other than dialysis), a patient at my hospital would need to be in the PICU.

BTW to the OP, another hint: your patient's malady is seen most commonly in young children and sometimes their pets!

Ed

He's got a gap acidosis and a metabolic alkalosis, but I see no evidence of ethylene glycol here yet without a measured serum osmolality. The ethanol itself can give you an anion gap.

 

[Hernandez]

He's got a gap acidosis and a metabolic alkalosis, but I see no evidence of ethylene glycol here yet without a measured serum osmolality. The ethanol itself can give you an anion gap.

and in my experience, very high levels of etoh can also give you an osmole gap, I've had 2 etoh levels >500 with (seemingy reliable) family denying any isopropyl/ethylene glycol/etc in the last month. but in that situation, what are you going to so? give fomepazole? theyre already self treating.....

 

[jdh71]

and in my experience, very high levels of etoh can also give you an osmole gap, I've had 2 etoh levels >500 with (seemingy reliable) family denying any isopropyl/ethylene glycol/etc in the last month. but in that situation, what are you going to so? give fomepazole? theyre already self treating.....

Of course the EtOH can give you high osmoles as well, but I don't have an EtOH level or a serum osoms in the stem . . . the calculated osoms based on the available labs isn't that impressive . . . but you are correct we almost always give these peeps the fomepazole anyway.

I don't think this guy goes to the unit. I agree with proman. Admit expectantly to mid-level nursing and follow some labs, put in the unit if needed later.

 

[proman]

Nice.

Perhaps the admission criteria for adults are different than children. We might be able to avoid dialysis with timely treatment. However, if using either of the appropriate medical interventions (other than dialysis), a patient at my hospital would need to be in the PICU.

There are pretty big differences. This guy needs a monitored bed with good nursing care. I've found that in pediatrics, that usually means the PICU. Adult ICU beds are so limited that a "just-in-case" admission is hard to justify. Of course, the results of the volatile alcohol screen could change all that.

BTW the guys behind fomepazole were geniuses. It's a drug that when given, the patient almost always needs dialysis. The drug is cleared by dialysis and requires redosing. You end up giving many more doses of it than without dialysis (q4 hours vs q12 hours). Much more $$ for the company ($1,000 a dose).

 

[Hernandez]

Of course the EtOH can give you high osmoles as

im not arguing, I'm just putting my 2 cents in on what I've observed myself that pure etoh in high levels can cause a small osmole gap (20ish) in addition to an elevated serum osmolality in my cases, it'd didn't change my management other than serially checking the osmole gapin follow up labs.

 

[jdh71]

im not arguing, I'm just putting my 2 cents in on what I've observed myself that pure etoh in high levels can cause a small osmole gap (20ish) in addition to an elevated serum osmolality in my cases, it'd didn't change my management other than serially checking the osmole gapin follow up labs.

I wasn't arguing either.

We've got a good old fashioned circle jerk in here.

 

[Hernandez]

Of course, the results of the volatile alcohol screen could change all that.

is it routine to get a volatile screen back quickly at other institutions? 90% of the time, they don't get it right even though it's a CPOE facility, and when they do send it correctly, it still takes over a week to get back.

 

[proman]

is it routine to get a volatile screen back quickly at other institutions? 90% of the time, they don't get it right even though it's a CPOE facility, and when they do send it correctly, it still takes over a week to get back.

The turn-around should be 1 day once the sample is received. Travel time will add to the delay. I happened to be in a city with a Quest reference lab so the results were available the next day. There aren't many places that run these tests.

 

[deuist]

To OP, just to point you in right direction, your patient has a known ketoacidosis. The three most common causes are diabetic, alcoholic, and starvation. Start with those and go from there. Also, your ABG shows a mixed disorder:
1. High anion gap metabolic acidosis
2. Metabolic alkalosis

Get a serum osmolarity and you should get the diagnosis. Just to cheat, I'm including my own article.

 

[bulgethetwine]

Nice.

Perhaps the admission criteria for adults are different than children. We might be able to avoid dialysis with timely treatment. However, if using either of the appropriate medical interventions (other than dialysis), a patient at my hospital would need to be in the PICU.

BTW to the OP, another hint: your patient's malady is seen most commonly in young children and sometimes their pets!

Ed

Yeah, if he was a kid, I'd understand the PICU. Didn't realize you were coming at it from that angle. I read the original post that emphasized the 50 year old patient, but your point is well taken and illustrates that kids aren't just "little adults" since the stakes are higher and the margin for error slimmer.

 

[staup]

To OP, just to point you in right direction, your patient has a known ketoacidosis. The three most common causes are diabetic, alcoholic, and starvation. Start with those and go from there. Also, your ABG shows a mixed disorder:
1. High anion gap metabolic acidosis
2. Metabolic alkalosis

Get a serum osmolarity and you should get the diagnosis. Just to cheat, I'm including my own article.

and a metabolic alkalosis from vomiting.

 

[deuist]

and a metabolic alkalosis from vomiting.

Shhh... he has to figure something out on his own or he'll never learn.

 

[vashisdead]

I was lurking the forums and found this thread. It caught my attention since I've been recently reading up on acid-base disorders and found some articles such as the following:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1297616/pdf/cc3789.pdf

I was wondering how popular this approach is in actual clinical practice. Would it be something worth delving into before a rotation in the ICU or should we stick to the traditional approach?

 

[ORL10]

I would get the serum osmosles just to be thorough, but the patient likely doesn't have an osmolar gap from AKA.

 

[jdh71]

I was lurking the forums and found this thread. It caught my attention since I've been recently reading up on acid-base disorders and found some articles such as the following:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1297616/pdf/cc3789.pdf

I was wondering how popular this approach is in actual clinical practice. Would it be something worth delving into before a rotation in the ICU or should we stick to the traditional approach?

Kellum has been stumping the physical chemical basis for acid-base for a long time now. I like that it allows you to wrap your brain around what's going on better, but I've never really found how it helps that much clinically

 

[vashisdead]

Kellum has been stumping the physical chemical basis for acid-base for a long time now. I like that it allows you to wrap your brain around what's going on better, but I've never really found how it helps that much clinically

So it´s nice to understand it, but you wouldn´t use it to determine a specific disorder and develop a treatment plan.

 

[jdh71]

So it´s nice to understand it, but you wouldn´t use it to determine a specific disorder and develop a treatment plan.

exactly - using strong ion thinking or classical acid base essentially gets you to the same place

 

[souljah1]

The Haber article is a brilliant approach that it rock solid in being systematic. I received this article as a med student (from the man himself) and have probably handed out well over a hundred copies of the thing to various med students, interns, and residents over the years.

 

[lura]

That Haber article was excellent refresher - thanks for posting link to the PDF file.