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INTERACTIVE CASE DISCUSSION. Acid-Base Disorders (Part I). Acid-Base Disorders (Part I). CASE #1: 24 y/o male with insulin-dependent diabetes mellitus 2 day history of fever and diarrhea BP=80/60, PR = 120/min, RR= 35/min,T = 39 C Dry mucous membranes, poor skin turgor, flat neck veins

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Interactive case discussion

INTERACTIVE CASE DISCUSSION

Acid-Base Disorders

(Part I)


Acid base disorders part i
Acid-Base Disorders (Part I)

CASE #1:

  • 24 y/o male with insulin-dependent diabetes mellitus

  • 2 day history of fever and diarrhea

  • BP=80/60, PR = 120/min, RR= 35/min,T = 39 C

  • Dry mucous membranes, poor skin turgor, flat neck veins

  • Clear breath sounds

  • Abdomen soft, hyperactive bowel sounds


Acid base disorders part i1
Acid-Base Disorders (Part I)

CASE #1:

  • Serum Na = 138meq/l

  • Serum K= 4.2meq/l

  • Serum Cl= 108meq/l

  • Serum HCO3 = 10meq/l

  • Glucose = 350 mg/dl

  • ABGs: pH = 7.30, pCO2 = 23 mmHg, pO2 = 92 mmHg (room air)


Acid base disorders part i2
Acid-Base Disorders (Part I)

QUESTION #1: What is the acid-base disorder present?

  • Metabolic acidosis

  • Metabolic alkalosis

  • Respiratory acidosis

  • Respiratory alkalosis


Acid base disorders part i3
Acid-Base Disorders (Part I)

ANSWER #1: Metabolic acidosis

ABGs: pH = 7.30 ()

pCO2 = 23 ()

HCO3 = 10 ()

pCO2 = ( 1.5 X HCO3) + 8

= ( 1.5 X 10 ) + 8

= 23 mmHg


Acid base disorders part i4
Acid-Base Disorders (Part I)

QUESTION #2: How will you systematically approach the present acid-base problem?



Acid base disorders part i6
Acid-Base Disorders (Part I)

QUESTION #3: What is the calculated serum anion gap in this case ?


Acid base disorders part i7
Acid-Base Disorders (Part I)

ANSWER #3:

Anion gap = Na – (Cl + HCO3)

= 138 – (108 + 10)

= 138 – 118

= 20

( Wide gap metabolic acidosis)


Acid base disorders part i8
Acid-Base Disorders (Part I)

QUESTION #4: In general, what are the causes of a wide anion gap metabolic acidosis?


Acid base disorders part i9
Acid-Base Disorders (Part I)

ANSWER #4:

Causes of a Wide Gap Metabolic Acidosis

  • Lactic acidosis

  • Ketoacidosis: diabetes, alcoholism, starvation

  • Toxins: salicylates, methanol, ethylene glycol

  • Renal failure


Acid base disorders part i10
Acid-Base Disorders (Part I)

CASE #1: Other Laboratory Results

Serum creatinine = 1 mg/dl

Serum ketones = negative

Serum lactate = 3 meq/l


Acid base disorders part i11
Acid-Base Disorders (Part I)

QUESTION #5: In this particular patient, what is the cause of the acid-base disorder?


Acid base disorders part i12
Acid-Base Disorders (Part I)

ANSWER #5: Lactic acidosis

  • No history of toxin ingestion

  • Normal kidney function

  • Negative serum ketones

  • Hypotensive with an elevated serum lactate


Acid base disorders part ii
Acid-Base Disorders Part II

Case #2:

  • 50 year old female with fever and diarrhea of two days duration

  • No previous illness; not on any medicines

  • BP =104/60, HR = 96/minute, RR = 30/min

  • Clear breath sounds

  • Hyperactive bowel sounds


Acid base disorders part ii1
Acid-Base Disorders Part II

Case #2:

  • ABGs at RA: pH = 7.30, pCO2 = 20, pO2 = 90, HCO3 = 8

  • Serum Na = 140 meq/L

  • Serum K = 3.6 meq/L

  • Serum Cl = 124 meq/L

  • Serum HCO3 = 8 meq/L


Acid base disorders part ii2
Acid-Base Disorders Part II

QUESTION #1: What is the acid-base disorder present?

  • Metabolic acidosis

  • Metabolic alkalosis

  • Respiratory acidosis

  • Respiratory alkalosis


Acid base disorders part ii3
Acid-Base Disorders Part II

ANSWER #1: Metabolic acidosis

ABGs: pH = 7.30 ()

pCO2 = 20 ()

HCO3 = 8 ()

pCO2 = (1.5 X HCO3) + 8

= (1.5 X 8) + 8

= 20


Acid base disorders part ii4
Acid-Base Disorders Part II

QUESTION #2: How will you systematically approach the present acid-base problem?


Acid base disorders part ii5
Acid-Base Disorders Part II

QUESTION #3: What is the calculated serum anion gap in this case?


Acid base disorders part ii6
Acid-Base Disorders Part II

ANSWER #3:

Anion gap = Na – (Cl + HCO3)

= 140 – (124 + 8)

= 8

( Normal anion gap metabolic acidosis)


Acid base disorders part ii7
Acid-Base Disorders Part II

QUESTION #4: In general, what are the causes of a normal anion gap metabolic acidosis?


Acid base disorders part ii8
Acid-Base Disorders Part II

Causes of Normal Gap Metabolic Acidosis

  • Gastrointestinal Bicarbonate Losses : diarrhea, small bowel drainage, ureterosigmoidostomy, jejunal loop, ileal loop

  • Renal Bicarbonate Losses : Renal Tubular Acidosis Types I, II and IV

  • Drugs : K-sparing diuretics, trimethoprim, pentamidine, ACE-I, NSAIDs, cyclosporine

  • Others: Acid loads, ketosis with ketone excretion, expansion acidosis, hippurate


Acid base disorders part ii9
Acid-Base Disorders Part II

  • QUESTION #5: In this particular case, what is the cause of the normal anion gap metabolic acidosis?


Acid base disorders part ii10
Acid-Base Disorders Part II

ANSWER #5 :

  • Diarrhea –due to Na and HCO3 losses


Acid base disorders part iii
Acid-Base Disorders Part III

Case # 3:

  • 65 year old male with nausea and severe vomiting of three days duration

  • Also with atopic dermatitis on high dose steroids

  • BP = 90/60, HR= 120/min., RR = 20/min

  • JVP = 4 cm,dry mucosa, clear breath sounds

  • Abdomen distended, active bowel sounds

  • Skin: poor skin turgor, multiple plaques with excoriations


Acid base disorders part iii1
Acid-Base Disorders Part III

Case #3:

  • ABGs at RA: pH = 7.50, pCO2 = 56, pO2 = 92, HCO3 = 42

  • Serum Na = 144 meq/L

  • Serum K = 3.6 meq/L

  • Serum Cl = 81 meq/L

  • Serum HCO3 = 42 meq/L

  • Urine Na = 5 meq/L, Urine Cl = 8 meq/L


Acid base disorders part iii2
Acid-Base Disorders Part III

QUESTION #1: What is the acid-base disorder present?


Acid base disorders part iii3
Acid-Base Disorders Part III

ANSWER #1: Metabolic alkalosis

ABGs: pH = 7.5 ()

pCO2 = 56 ()

HCO3 = 42 ()

pCO2 =  0.75 (HCO3)

=  0.75 (14)

=  10.5

pCO2 = 45 + 10.5

= 56


Acid base disorders part iii4
Acid-Base Disorders Part III

QUESTION #2: How will you systematically approach the present acid-base problem?



Acid base disorders part iii6
Acid-Base Disorders Part III

Question #3: In general, what are the causes of metabolic alkalosis?


Acid base disorders part iii7
Acid-Base Disorders Part III

ANSWER #3:

Causes of Metabolic Alkalosis

  • Chloride Responsive (Urine Cl < 25):

    Vomiting, NGT suction, diuretics (late), factitious diarrhea, low Cl intake, posthypercapnia, cystic fibrosis


Acid base disorders part iii8
Acid-Base Disorders Part III

  • Chloride Resistant (Urine Cl > 45):

    Primary mineralocorticoid excess, diuretics (early), alkali load, Bartter’s or Gitelman’s syndrome, severe hypokalemia


Acid base disorders part iii9
Acid-Base Disorders Part III

QUESTION #4: In this particular case, what is the cause of the metabolic alkalosis?


Acid base disorders part iii10
Acid-Base Disorders Part III

ANSWER #4: Vomiting

  • History of vomiting

  • Signs of dehydration

  • Urine chloride = 8 meq/L (< 25), Cl responsive type of metabolic alkalosis


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