1 / 39

INTERACTIVE CASE DISCUSSION

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

freya-hale
Download Presentation

INTERACTIVE CASE DISCUSSION

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. INTERACTIVE CASE DISCUSSION Acid-Base Disorders (Part I)

  2. 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

  3. 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)

  4. Acid-Base Disorders (Part I) QUESTION #1: What is the acid-base disorder present? • Metabolic acidosis • Metabolic alkalosis • Respiratory acidosis • Respiratory alkalosis

  5. 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

  6. Acid-Base Disorders (Part I) QUESTION #2: How will you systematically approach the present acid-base problem?

  7. Acid-Base Disorders (Part I) ANSWER #2:

  8. Acid-Base Disorders (Part I) QUESTION #3: What is the calculated serum anion gap in this case ?

  9. Acid-Base Disorders (Part I) ANSWER #3: Anion gap = Na – (Cl + HCO3) = 138 – (108 + 10) = 138 – 118 = 20 ( Wide gap metabolic acidosis)

  10. Acid-Base Disorders (Part I) QUESTION #4: In general, what are the causes of a wide anion gap metabolic acidosis?

  11. 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

  12. Acid-Base Disorders (Part I) CASE #1: Other Laboratory Results Serum creatinine = 1 mg/dl Serum ketones = negative Serum lactate = 3 meq/l

  13. Acid-Base Disorders (Part I) QUESTION #5: In this particular patient, what is the cause of the acid-base disorder?

  14. 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

  15. 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

  16. 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

  17. Acid-Base Disorders Part II QUESTION #1: What is the acid-base disorder present? • Metabolic acidosis • Metabolic alkalosis • Respiratory acidosis • Respiratory alkalosis

  18. 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

  19. Acid-Base Disorders Part II QUESTION #2: How will you systematically approach the present acid-base problem?

  20. Acid-Base Disorders Part II QUESTION #3: What is the calculated serum anion gap in this case?

  21. Acid-Base Disorders Part II ANSWER #3: Anion gap = Na – (Cl + HCO3) = 140 – (124 + 8) = 8 ( Normal anion gap metabolic acidosis)

  22. Acid-Base Disorders Part II QUESTION #4: In general, what are the causes of a normal anion gap metabolic acidosis?

  23. 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

  24. Acid-Base Disorders Part II • QUESTION #5: In this particular case, what is the cause of the normal anion gap metabolic acidosis?

  25. Acid-Base Disorders Part II ANSWER #5 : • Diarrhea –due to Na and HCO3 losses

  26. 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

  27. 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

  28. Acid-Base Disorders Part III QUESTION #1: What is the acid-base disorder present?

  29. 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

  30. Acid-Base Disorders Part III QUESTION #2: How will you systematically approach the present acid-base problem?

  31. Acid-Base Disorders Part III

  32. Acid-Base Disorders Part III Question #3: In general, what are the causes of metabolic alkalosis?

  33. 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

  34. 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

  35. Acid-Base Disorders Part III QUESTION #4: In this particular case, what is the cause of the metabolic alkalosis?

  36. 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

More Related