Morning Report: 4/10/2014

by Jay Khadpe MD • April 10, 2014 • Comments Off

Here’s Dr. Freedman with today’s Morning Report!

Delta Force

An approach to the possibly complicated metabolic acidosis

1^st What’s primary?

Compensation is alright, but its never enough
Ph?
What’s the respiratory system doing?

2^nd Gapped or non-gapped?

Normal AG?
Gapped
- MUDPILES
- But what are they really?
  - Left Total Knee Replacement
    - Lactate
    - Toxins (-OHs), Salicylates
    - Ketones
    - Renal

Non-Gapped
- ABCD
  - Addisons
  - Bicarb loss (GI or renal)
  - Chloride Excess (iatrogenic)
  - Drugs ( carbonic anhydrase)
  - HARDUP
    - Hyperalimentation
    - Addisons
    - Renal
    - Diarrhea
    - Uretorocolonic fistula
    - Pancreatic Fistula

3^rd How’s my AG respiratory compensation?

Winter’s
- 1.5(HCO3) +8 +/-2 = pCO2
Quick and dirty
- Last 2 digits of pH ~ pC02

4^th Delta-Delta

I’ve got one; do I have two?

Change in AG / Change in HCO3
- (AG – 12) / (24 – HCO3)

Delta ratio

Assessment Guidelines

< 0.4

Hyperchloremic normal anion gap acidosis

< 1

High AG & normal AG acidosis

1 to 2

Pure Anion Gap Acidosis
Lactic acidosis: average value 1.6
DKA more likely to have a ratio closer to 1 due to urine ketone loss

> 2

High AG acidosis and a concurrent metabolic alkalosis

or a pre-existing compensated respiratory acidosis

Reference:

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