Blood Gas III




© Springer International Publishing AG 2017
Tilak D. Raj (ed.)Data Interpretation in Anesthesiahttps://doi.org/10.1007/978-3-319-55862-2_38


38. Blood Gas III



Pramod Chetty1  


(1)
Department of Anesthesiology, OU Health Sciences Center, 750 NE 13th Street, Suite 200, PO Box 53168, Oklahoma City, OK 73104, USA

 



 

Pramod Chetty

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Keywords
Diabetic ketoacidosisNon-ketotic hyperosmolar hyperglycemiaKetone bodiesDehydrationInsulin dripHyperkalemia


A patient with closed fracture of the lower extremity is scheduled for an ORIF. The patient is an unaccompanied, slender, 26-year-old male who cannot give a good history due to confusion and has deep, rapid breathing with a distinctive odor. His vital signs show mild hypotension, tachycardia, and low-grade fever. Investigations demonstrate Na+ 132, K+ 4.8, Cl− 92, HCO3 − 12, BUN 24 mg, creatinine 1.6 mg, Ca++ 7.8 mg, and blood sugar of 318 mg/dl. Arterial blood gas shows a pH of 7.24, PCO2 28, PO2 76, HCO3 12, BE of 14, and O2 sat of 93%. His CBC is normal with mild leukocytosis and evidence of hemoconcentration. The chest X-ray is unremarkable and EKG shows sinus tachycardia.


  1. 1.


    What is the likely initial diagnosis of this patient and how can you confirm the diagnosis?

     

  2. 2.


    What are abnormal laboratory values in the BMP and ABGs that are seen in this condition?

     

  3. 3.


    What is the major differential diagnosis in this clinical condition?

     

  4. 4.


    What are the principles in the treatment of this condition?

     

  5. 5.


    How do the results of the BMP and ABG trend during the treatment of this condition?

     

  6. 6.


    How will you continue management of this patient with the planned surgery?

     



Answers


  1. 1.


    The presentation of this young patient with altered sensorium, “Kussmaul” breathing, hyperglycemia, and metabolic acidosis strongly suggests diabetic ketoacidosis (DKA). The diagnosis can be confirmed by the presence of ketone bodies in the urine and serum [1]. Concomitant lactic acidosis must also be investigated [2, 3]. As with any patient with a traumatic injury and altered sensorium, radiological testing for cervical spine and cranial pathology must be done.

     

  2. 2.


    The laboratory values in DKA will show evidence of metabolic acidosis, electrolyte derangements, and evidence of severe dehydration [4].


    1. (a)


      BMP



      • Na+—there is a total body loss of Na+; the levels can be low normal. Correction must be made for undermeasurement of Na+ due to hyperglycemia (add 1.6 meq/L to the measured Na+ for every 100 mg of glucose above 100 mg/dl level).


      • K+—there can be a significant total body loss of 3–10 meq/kg of K+. The initial serum K+ level may be paradoxically high due to both volume contraction and decreased movement into the intracellular compartment [1].


      • Cl−—will be decreased.


      • HCO3 −—will be decreased.


      • Anion gap—will be increased above normal 10–14 meq/L [5]. This gap is calculated by the formula:



        • AG = Na+ − (Cl− + HCO3 −)


      • BUN—will be increased.


      • Creatinine—may be mildly increased.


      • Ca++—may be decreased. Additionally magnesium and phosphate depletion can also occur.


      • Glucose—increases to levels greater than 250–600 mg/dl [4] but rarely may be normal, when called euglycemic DKA [6].

       

    2. (b)


      ABG

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Sep 23, 2017 | Posted by in Uncategorized | Comments Off on Blood Gas III

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