Here’s Dr. Aldokhi with today’s Morning Report!
AG Acidosis
Case 1
| HX | 29 YOM no PMH , sent from CPEP for abnormal labs, patient has unspecified psychosis, no etoh, no drugs |
| Px | Vitals normal, dry MM, flat affect rest of exam within normal. |
| labs | CBC 12.5>15.5/46<318 CMP 142/4/99/18/39/1.2<73
AG 25 pH 7.3 UA ketones , serum Osm 312, calculated lactate 1.4 methyl -ve |
| Dx | Starvation ketoacidosis |
| Rx | Hydration with glucose |
Case 2
| HX | 80 YOF with AMS, has crohn disease, arthritis , take Tylenol for pain, hypothyroidism, Afib, take mesalamine, PPI, levothyroxine. |
| Px | Vitals normal, dry MM, cachectic, does not follow command , rest of exam within normal |
| labs | CMP 138/4.7/108/11.3/30/1<78 serum albumin 1.5
AG 19 Corrected AG 25, pH 7.3, serum Osm 309, lactate 13 , urine positive for 5-Oxoproline |
| Dx | Tylenol with malnutriention (depleted cysteine) resulted in 5-Oxoproline acidosis |
| Rx | D/C acetaminophen and give NAC |
Anion gap (AG), representing the difference in concentration between measured cations and anions
ED approach to AG acidosis:
- Correct AG to albumin (add 2.5 mEq/L for each 1 mEq/L decrease in albumin)
- Hx of diet, alcohol (ethanol, methanol, ethylene glycol), renal failure, medicine (metformin …)
- Labs (CMP, OSm, ketones, acidosis, lactate, ASA…)
- Relation of [HCO3–] to the AG.
- Remember MUDPILES
| Category | Examples |
| Renal failure | Uremia |
| Lactic acidosis | Sepsis, shock, liver disease, isoniazid, iron, carbon monoxide, methemoglobin, metformin, and cyanide |
| Ketoacidosis | Diabetic ketoacidosis, alcoholic ketoacidosis, starvation ketoacidosis |
| Ingestions | Methanol, ethylene glycol, salicylates |
M – Methanol
U – Uremia
D – DKA / AKA
P – Paraldehyde / paracetamol
I – Iron / INH
L – Lactic acidosis
E – Ethylene glycol
S – Salicylates
The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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Jay Khadpe MD
Editor in Chief of "The Original Kings of County"
Assistant Professor of Emergency Medicine
Assistant Residency Director
SUNY Downstate / Kings County Hospital
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