CASE ABG



CASE  ABG

A 77 yo man presents to your ED feeling generally unwell for several days. 

He has a pulse rate of 36/minute and a BP of 150/80.

ABG and some biochem is performed.

Questions:

1. Describe these results.

2. What other investigations will you do ?

3. How will you manage this man ?

ABG

FiO2                    0.3                        

pH                         7.19                 

pCO2                  30                 

pO2                     119                

HCO3                 14             

Base excess     -15    

SpO2                    97%          

Na                          132          

K                             6.9          

Cl                            98         

Creatinine         1050   

Urea                      49.4   

Glucose               6.1   

Lactate                3.5    

Digoxin               5.9

Answers

1. Describe these results.

Acid Base Status

• there is a moderate metabolic acidaemia (HCO3 14, Base excess -15)

• respiratory compensation is appropriate (Winter's formula)

• Anion gap is elevated - 20 if you don't include K ; 27 if you do

• Delta ratio (increase in anion gap / change in bicarb) = 0.8  - a borderline number

Electrolytes

• Na - mildly low, no need to correct for glucose

• K - hyperkalaemia - given pH, this is both overall K excess as well as extracellular shift (correcting to pH 7.4 would be expect to drop K to 5.9)

• Urea + Creat : impressively elevated, suggestive of severe ARF (or ARF on CRF). High urea ratio makes you consider prerenal cause, but urea : creat not that high. Other considerations such as post renal (especially in an old man), or intrinsic renal pathology remain on the table.

Oxygenation

• Using alveolar air euqation, A-a gradient is 57 - ie elevated.

• Concerning for shunt - new or preexisitng respiratory pathology.

Others

• Digoxin level = 5.9

- this is a very high level and indicative of digoxin toxicity - a life threatening diagnosis

- given the stem, it is likely this is chronic toxicity, precipitated by renal failure rather than an acute overdose

What other investigations will you do ?

• ECG - looking for AV block (note bradycardia), pseudonormalised slow AF (almost pathognomonic of digoxin toxicity) or other abnormalities of conduction & automaticity

• Ca / Mg / PO4

• Bladder scan / ED POCUS - post renal ARF needing IDC

• Medication review - precipitants of ARF

• Septic screen- as driver for ARF

• Volume assessment - likely to be dry

How will you manage this man ?

• This man has acute renal failure with a raised anion gap metabolic acidosis and chronic digoxin toxicity - he is critically unwell an needs to be managed in resus or time critical in a monitored bed.

• Good IV access

• IV fluid to rehydrate - this may well also drop the K

• Digoxin immune Fab - 2 vials in 100mls NSaline over 30 minutes 

May need more - review after this and see - can work out amount needed based on dig level and weight - but I would suggest getting it started and then breaking out the calculator !

• Insulin + Dextrose for hyperkalaemia - avoid Calcium in dig toxicity (some debate around this)

• IDC

• Will need dialysis - refer ICCU (vascath, RRT and close watching)

CASE - The swollen toddler...

A 3 yo boy is brought to ED by his concerned parents who have noticed he has put on weight and appears to be puffy. As a routine, one of the nursing staff obtains a urine which they notice to be quite frothy.

What clinical syndrome does this young boy have ?

Why is the urine frothy and what do you expect the disptick to show ?

What are the causes of this presentation and what are its complications ?

How are you going to manage this young boy ?

[pic][pic]

Answer

1. This young boy has Nephrotic syndrome.

Nephrotic syndrome is a manifestation of glomerular disease (a constellation of signs and symptoms) rather than a specific diagnosis. It is characterised by :

- proteinuria > 40mg/m2/hour (3.5g / day in adults) or morning urine prot:creat ratio >200mg/mmol (3-4+ on dipstick)

- hypoalbuminaemia ( ................
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