‘weno Neun Fluids and Electrolytes Challenge Disorders of Fluids and Electrolytes “The case description below highlights issues raised in an upcoming Disorders of Fluids and Electralyies review article, A 64-year-old man wth agtation and a history of alcohol ‘use has been brought to the emergency department. His laboratory data incide: blood pH 7.07, Po, 12.6 mm Hg, Po, 55 mm Hg; sodium 133 mmole, potassium 4.1 rmmotier chiosge 93 mmotiter, and bicarbonate 3.8 mmole, What strategy Would provide the best support for this patient? Polling and commenting re now closed. The stor’ recommendations spear next change appears on November 26 The Integration of Acid-Base and Electrolyte Shoe Disorders 3 Comments and Pol open through November 4, 2014 Presentation of Case 'R t-yea-ld man wha Fistor of alcohol abuse and hypertension was comatose when he aved in the emergency deparimert, but he awakened quickly and was agitated. His intial blod pressure inthe ‘emergency department was 100/80 mm Hg. is weight was 68 kg (approximately 150 Ib), ae his hight ‘was 170 em (67 in). He was afbile. Theil aboralory ata included a Namoglobn vel of 8.0 g per Gece, sodium 133 mmal per iter,potassium 4-1 mal perlite, eheide 83 miro per Iter, ana bicarbonate 3.9 mmol per itr. Tho anion gap was 38.1 mmol pe Iter. The patent's albumin evel was 3.09 por ocr, calcium 80 mg per deciiter (2 mmal pers), and magnesium 1.9 mg por decir (0.78 mmol perlite). Atrial boos gas analysis showed a pH of 7.7, partial pressure af carton doxde (02) 12.6 mm Hg, and partial pressure of onygen (Po) 85 mm Hg, The lactate level was 14 mmol per "te, plasma osmataty 330 mOsm per klgram of water, and plasma creatinine lve 2.8 mg per eciter (248 pmol per ite). His aminotransferase levels were slevate, ‘Thos findings. at fst, appear o be consistent with Wver cise, bt you wonder whether he patient tp stew jm oadostry10,t0S6feature. 2014 1021.32 ‘SUBSCRIBE OR RENEW Incldes NEJM iPad Eton, 20 FREE paint? Inne veut nth eta rahypyrazo)baceuse ot cna "tsp gesten onto helo rebrand every farce Inte da gu pss he suspon os rateen eee aed Poll cored November 5, 2014 (Gset td Response ve‘weno Neun ight als have habdomyolysis, Futhermere, he s anemic and nary Ketones ar presen tndngs Consistent wt station o alcohol ketoacidosis, Given thasefdings ard the pabont’s hisory, he ‘may have ingested a toxin auch a8 ethylene yea! o methanol. The fsngs inthe urinary sediment — ‘ark granular casts nd many erytals— ae content wlth the presence of calcum oxalate, Because Of the patent's severe acidemia and hyparvetlation with poor oxygenation, macharlcalveslation Question What strategy would provide the best suppor fortis paint? Polling and commenting a ‘closed, The editors recommendations appear below. Answer This pation has severe acidemia with an extremly lw Pcoz Ho is hypochloremic wth a very igh rie gap, The caeated gap (28.1 mmel pa ters probably ower than ise gap ven the ow ‘sum albumin level Inthe paysicachomical mode, al aon ar aon concairatens are considered ‘and must Balance, Thu, the slong ion afeence (SIO) cleuated fo mma per Her ae [Na"] + [6°] + (632 + (a?) [CF] = fal eter anions), 2 12+ 4.1 + 20 + 0.78~ 99 ~ (all ther aries] = 45.88 = fall othr ins ‘The anion gap equation could be rearanged to lve for bierbonal nstea of unmeasured anions — |e, {Na"} ~ (Cr + [anon gpl) = [HCO;"] — analogous to he SID. Ingestion ofan agent such as tthylene lye! or methanal wouls be compatible wth th patent's esmolar gap and arian gap, 2a well {95 his renal faire. The presence of calcium oxalate crystals in his urine sediment would suppor @ dagrosis of ingestion of ethylne glyco"? An increased osmelar gap may aso occurin cases of ‘thanl or acatone ingestion. Alcoholic ketoacidosis is possible given the Ketonuri, but k seers tkely ‘hat he hie ingested ethylene glyco. His ow blood pessur. fiver disease, and aneia wih lw oxygen ‘saturation ar consistent vith ate acidsis, You note that he had had a seizure, he could Nave 99 acute lacie acidosis supernpased ona tox ingestion. However, a false elevation in the tele level has been Seen wth ethylene ayea oxety? ‘There is also some evidence of hypechloremic metabolic alkalosis. The ations chord ove is om, yt withthe dogre of hyperventilation, cre would expect an slvated chord ove, sos has had major lorie losses. Chori is probably moving inlo cel, and ne has probably had vrriting, wich eats to ‘metabo alkalosis ‘One would nots thet this patient cout alse have a component ef primary respiratory alkalosis, since Ne Is hypoxamic and anemic, and he may have pneumonia. That would compensate to some degre fr the ecreased chloride evel. Howaver, the severty of his acidemia rndors the situation beyord te iit of compensation te may be use to provide supportive cave with glucose and Mids containing bicarbonate (Sati) nti etntve taatment occurs.” Howover, tis therapy alone snot optimal and wi nt do much fer a pation with @ pH of 7.07. One should consi therapy that wl help to eliminate the toxic metabo. Thus, one should consider etharl ison’ or, atematively fomopizol, "van tha clinical suspicion of ‘thylene gical intxicaton an tha soverty of te acidemia, Fomepzoe, whichis a compettva innbilr of alechaldehyérogeraso, wil provent futhor formation of melaboos of ethylene lycol and ‘methanol. However, data are inconclusive regarding wheter ethane infusion or adinistraion of fomepzce is most approprit,* and the ually of xvid stasis is ited, In ay case, may be ‘most helpful to nat dalyss or continuous venovencushemefitraton, given the We-tveatening nature ‘of the potential cagnoses. ™"® One snoul omen that nemadalysis algo removes nor terapy, 0 higher mantanance doses of etnanal and fomepizcle are reqied Related Review Article To read mote, see Integration of Acie-Base Disord, an ail about acidosis in our Disorders ot Fluids and Elclyies sens, by JL. Softer, nthe November 8 issue of the Jouma References. 1. ruse JA, Mathanol and ethylene leo! niosicaton, Cai Cre Cn 2012,28:661-711, 2 RigurT, Get, MongaréonN, Bourgogne E, Pane F. False hypesactatemia in ite- Itveatening etylene glyco! posaning. Ann Fr Anesth Rear 2016 386)079-08% management of etylene veo! plsering:impodance of eystaluie: apropos ofa ease Nephologe 199%; 14:221-8 (In Franch.) 4 Chow MT, Dt Sivesta VA, Yung GY, Nawab ZH, Leehey Du, Ing TS. Treatment of acute ‘methanol toxestion vith hamadaysi using an sthanebeniche, bleabonate-based dalysate. Am J Kieney O's 1997;30:588-70, 5 BargeronR, Cardinal, Gaadah D, Prevention of methanal toxic by thanal therapy. Engl Mod 1962:307- 1828, bt stworw jm oadostry10,t0S6feature. 2014 1021.32‘weno Neun 5 Beaty L, Green R, Magoo K, Zed P. A systomaic review of ethal and fomepizco use in oxi alcohol ingestins. Emory Med Int 2013:2013:530057 7 Bren J. Femepzol for thylne glycol and methanol poisoning. N Engl! Mos 2009;360:2216-28, 8 Brent J, MeMartnK, Philips S, etal. Fomepizle forthe treatment of ethytne glyco poisoning, Engl J Mos 1999;340 632-8 Bron J MeMartinK, Philips S, Aaron C, Kul K. Femepizle fr the treatment of methanol poisoning. N Engl J Med 200184: 424-9 40 Cheng JT, Beysolow TO, Kaul Beta, Clearance of ethylene aye by Kidneys ard hemodialysis. J Clin Toxicl 1987,25:95-108, 11 Jacobsen 0, Ovebs S, Ostborg J, Sjested OM. Glycolale causes the acidosis in ftylene glyco! poisoning ands effectively removed by hemodiaysis. Acta Med Scand ‘984;216:400-16 12 MeCoy HG, Cipla RU, Enlre SM, Sawchuk RU, Zaake DE, Severe methanol poisoning ‘applaton ofa phamacakinetc modal fer ethana therapy and nemodialsis. Am J Mes 197 0:7:804-7, How would you manage this patient? 118 READER'S COMMENTS. rok Masa Str Dc None A ite calculations |i not undestans why the most people vate for treatment with glucose? Ieincease osmolarity and may be aso the lactate, dest it? Wha isthe composition of 330 mmale porter montioned as osmolarity? Is thre slovated ure, glucose, acetylacotate, pyruvate or something els6? Bt ay Pits ‘he sum of 193 (Ms) + 93 (I) + 4.1) +39 (ICO) + 045 (A) + 14 mrss (Lac) i only 250 mmot, so thing there shouldbe the question about ‘compost of esting 80 mel. JAGANSOU? SHOR | Pysan- INTERNAL MEDICNE | Bacau None Acidomia Ir seems that he has high AG & 00 metaboe acidosis and probable associated reepratory acisoas (? ‘aspiration pneumonia) is metabole aldose det Ketacioie ue to starvation & more likely alechol ksteaccosis are assocated NADH ervenlctic acidosis (NADH 's requted for alechol metabolsm, g2neratod by anaerobic slycoyss, which gonerats lactate) howover loss kely but possible hypopertsion could also play arte in lactate generator High OG and crystal in une is suggestive of is dark urine and granular ast de to ATN i also addtional probabil =NsHeO3 -Forspizole oe “thiamin boore considering dextrose considering empire anarob coverage Abe HO woul be appropiate if sbove unsuccessful nissan Pyscan-HosotlMedho | scbsre None plan of management Ns tp stew jm oadostry10,t0S6feature. 2014 1021.32‘weno Neun Soi bi Carb Fomepizcl Diaysis Leonard Caras Sn Dslr: Nene ‘ora Dialysis, no doubt Its vary clear, hematlalyss fst beacause the patient has a severe real fale and hes going to det wo dont dot Thon the spocfictratamert of ethylone glcalintoxictin. ory easy. I's @ very commen presertaton in an emergency seni. do alto that. NaN Luts CLAUOIO GONZALEZ | Suter | Deca: Ne Novaer 04, 2014 Isotenic bicarbonate solution, fomepizole and consultation for dialysis Need to considera noproogist consultation for consideration of homedialyss inthe meantime | would ve the pl fomepizoleand_ lume expansion withioloric bicarbonate soliton, Etheylene glycol poisoing ‘The finding of seule wide anion gap metabolic acidosis wih larg esmol gap and oxalate ertysilina ‘are sugestve of sthylone lot poisoning, He should be rated with lomepizte and immediate hamedialyss ICHAD NG, MO Prysicin NEPHROLOGY Dict Nore Noxt step in Managment. Nesce diel st, fled by fomeszale, Fompazcle wont test the acidole, dlls wi ‘ethylene glycol intoxication In my point of view, this isa clinical cate of ethylene cal ntaxication (anion gap metabolic acidosis, ‘ata plsmatic osmolaty (SémOsmolkg). increased plasmati lactate (NADH), urn oxalate crystae (qlycoraat) elevatod aminatransferases, creatinine elevated. Treatment options: infusion of etnarolo ‘more recat, fomopizle, but never loge: Dialysis uae, tel usepse nvarotecara | Stet Oscbsue: None Canna tty to avoid dyalisis fits possible This patient hasan metabolic acidosis wth high gap and pH I 7.07, $0 | would give him sodium bearborate unt his pH ges to 72 also would give him fomepiza leis necessary dextrose 5% un saline 0.9% too, I he does get blir dass is necessary to ix the acute kidney iniry ARTICFUROHIT, MD | ase - CARDIOVASCULAR DISEASE |Daceue:Nane Novena 2014 alcoholic ketoacidosis pation looks to be at present intoxicated wih alcoho, ‘may have aspirated and thts why low 8pO2 ‘neamia may be dit to crvorie GI beeing tp stew jm oadostry10,t0S6feature. 2014 1021.32‘weno Neun at prsont beter to start with dextrose intsion Insert data forthe agnosis WL MARTIN, | Pysen - NEUROLOGY | Ose: Hone VeTORIA SC Canaan electrolyte replacement Dom forget posse, ‘DANIEL URRACH ND | Ps INTERNA. VEDICINE sche None PORTLAND OR | Osmotar gap COsmolar gap suggestive of metnanol or ethylene alycol. Fomepizole is appropriate empire nerapy ANTHONY AGOSTINO, MD [Prysean- INTERNAL MEDICNE [Dscecre Nene dialysis agree wih 3fP and preparation for dialysis given the histary, the lage AG acids, the need for mare info andthe potential mority and high risk of mortally with dlayed treatment CovANNISALAMANO, MO | Pryian- GENERAL PRACTICE |Decbeure None VERCELLINay| The sea inside us. ‘The rol of slectsyte measurement is too ft misunderstand in Goneral Practice. So that also measurement of serum clo is forgotten in proserbing dosage of rum elects; thinking that only ‘sodium and potassium ions should give us important informations on paints homeostasis. The crical case her represented ard the Review Al recenty published op The Jounal remember us the relevance of clue, Bcaronste, clcum, magnesium and phosphates n understancing how important |e thelr presence and regulation in ody ids, Acidbase equlltriam fe tightly regulated by an interplay cf harmnal and intresllar responses pres: in all our body tissues and in particular st kcney level, ‘These "bizare" equations such as Arion Gap (increased inthe patient under cscussion 38 mmol!) AlvoolarArtorial oxygon gradiont rat in this patient 041 and 73 mg) foronce in rion Gap (in ‘he patient 28 mma , Deka GAP and ratio (Mere 3 mmal and 1.1) reused mainly by noproogist foloning dtc patos That's wy I find very sell the Review Articles on regulation ofthe * seaside us © SHAOMING HUANG, MO[Pryscan NEPHROLOGY | Decksut: None CINerar OF Multidicipting actions required simutaneously This sa ertiea! ness pales, none of pol strategy options Is enough forthe bedside care for his patos. The readers of his Jounal are global. Therefor the teaching pots shouldbe pacinent to tis kind of pation caro al fret clical settings. Sack to this patos, based onthe info prowded, this pation had ethylene glycol ingestion proven atherise. Ths patent needs to be rosusctatod very fogressvely, With of 7.07 and serum bicar of 3.9 he woul have cara collapse very S00", He reeds Iv fi st Before ary glucose containing soln given he should get a dose of hamine to provent Wlomickes encephalopathy, NS woul bean inappropriate Soh a tots ow pH (rors 5) his case (his BP isnot 10 bad yet. Bear based soln woud bea attr option. Hs K was ony 4-7 with Hof 7.07. Thus, Ns K pool was depleted. Therefore, he wll eed K supo! aggressively well Fomepacle shoud be stared mms ie aval, Etnanal infusion ie as affective, Dalysle should ange immediatly to, His phos love shoul be obtained and replaced as necessary. ‘The lab is taking a long time to get us some basic data Ik-dossnt seem que fio keep key data that would usualy be ready avaiable fram us (CXR, CMP) But there aro clar ina ndings that shouldbe ignored, Thesis a high anon gap. an almost completely componsatod molaboc acidosis a probably high osmolal gap (whoro is hat SUN and tp stew jm oadostry10,t0S6feature. 2014 1021.32‘weno Neun {GW??), and probable calcium oxalate crystals inte urine. This Scroams ethylene glycol and fomepizle shoul the drug given inmadatly sf the usual nial Ramin, oat, intubation meds otc, Hoksng back on fomepizole because of incomplete ta might possible lze this patent. ‘The pHi below 7.1 a carlac depressant and shoud be treated with some HCO03. Despite beng fbr, the low oxygen levels suggests a pulmonary issu, likely an aspiration or ther pneumonia. Hs high lactate lovel may be an outcome of sepsis and antbcties shuld be inated Alls is while waiting to set he patient up for herediayss, the dtrive treatment of the unkown ‘nin causing the high osmelany and whe waiting for th hidden In results to come back on Nov 6 Hemodialysis. Definitely ths pation has two ineatins for uskg bemedayss: + igh anion gap matabete acidosis 2 (GSE>RE FANRJLARO, MO | Pylon INTERNAL MEDICINE | Ossie None Rowstal What about sepsis? High anion gap acidosis. Probable ethyl yoo! er methanol naxiaton, What about sepsis? soars Rests Urersta Vin Satta ins | Rect Aneta | Dace None tay ur opinion: dialysis. This pation presents a severe uncomponsatod metaso acidosis wih elevated anion gap, a severe hypoxic respiratory fale, a possibly end stage Iver disease and ronal are, Imetant data are lacking: ammonium, gluce, iuess, that may rule out hepalornal syndrome, However, ethylene cole intoxication fs also a possbty due to several elements: Acute renal fal due to tubular obstruction fom precipitated oxalate erystae, elevated arian gap, eerie abuse. Elevated plasma lactate dos notre ou tis hypothesis since some insttuments can't eiferentiate between lactate and 9ycotate-Taking into account tho severty ofthe circa situation tho best choice fr this patients. hameciayss, n ere to restore volemia an eliminate toxins cling matnanal ang ethylene dlyel “Tho use of encots lke fomepizale has been excluded by most of us because incu opinion thie Station requires an agressive treatment and fomapizele has an unacceptaéle atony of effact. Other supportive thorapies include hyeatin and the acminstaion of Solum bicarbonate, oe acid and falvamin, Azzolni ML, Bocchino S, Burtt, Cort D, Mont! A, Pa M, Sivet . sa Sara Physi - Fem enarGenera cic | Dscbsue None Metabolic acidosis with high AG ‘According to enstence data the pint hs metabolic acidosis wih high AG. seems to be mixed ‘eins due to (patient AG-NI AGY{NM Haspatint HCa3)>1 probably because af vomiting Mappened, ‘The most likely dagnoss is ethylene glycol poisoning and the best treatment is duress, fomepzole and \vtamin suplements(pyrdoxin & thiamin), but asthe patian hae PH72 andthe AC>20 he has the indication of emergency hemodialysis, YAzIEo CHOTHI, MD [Phys - NEPMROLOGY | Dacha None Ethylene glycol poisoning (EGP) Firstly, the measured plasma osmolality of 330mosmikcg is raid (the osmolal gap cannot bo calculated asthe urea and ghcose is not esclosed). This clearly means thal here isan unusual osmole added to ‘he plasma, Thus, @ oxi alcohol must be considered, AKI and Ca-oraat crystals nthe urine Suppo EGP. ‘Secondly, a high AG metabolic acidosis (361ml) is present (even when corected forthe serum ‘loamin. This isnot fly explained by the righ acta. This is tkaly the anion of alycolc acl. Als, th Llactate may be falsely elevated in EGP i the onzymatic method (Llatato oxidase) s used, Usvaly found in ponto-care AAG machines. K another analyzers used to meaeure Lactate (e. tp stew jm oadostry10,t0S6feature. 2014 1021.32‘weno Neun ISTAT, Baye), the measured Lactate may be normal anda lactate gap willbe present (erence between the anzymatiemathod and athe: analyze method, Due tothe sovtty ofthe metabae acide, the kay presence ofa raised osmotal gap and AK! Uugert hemodialysis (HD) is inleated. While awaiting HO intiation,fomepizole shouldbe gven to prevent furnar conversion of EG to gyeai ac, ‘NAN FOY. YO Fyn INTERNAL MEDICINE | care Nore Acidosis and ethanol |agre the agnosis is thay to be etrylene glycol poisoning in an alechol dependant patient, Ho doos have lacie acigosis as well and it shouldbe pointed at that Ketones ae nt usualy found in altel ketoacidosis because the acidosis is due to bola hyeoxybtyrate which is ot detected by the usual test for ketones which only measures aestoaceate, Also, gving bicarbonate would be hazardous because hs potassium ls already onthe lw side and may fl preciptously Wf he acidosis fs comected 120 qukly. His otal body potassium is almost coral ow. arco Marans, MO Prystcan-Gasvoerardoy [csi Nowe tay Do not forget hemodynamics ‘Thee i high anion gap metabo acidosis, but the amount of lactate oss’ justify 20 high anion gop. High plasma osmolality (n respect to Na value) let me suggest poison and ethylene cal toxicity s @ possiily, novoverfomepzole cannot be appropriate therapy due to rnal. thnk als to metformin toxicity. Thor is fw atrial oxygenation wih high alveclarartral raiet (78 mm) esp hyperventilation and CPAP wih high FIO2is the appropriate. Final | woul! ook at hemodynamics especialy if have to cary ext ays {place a aysis catheter in internat guar vein. Now ean take a ook at OVP and conta venous ‘oxygen saturstion inking to EDGT). | can compute oxygen extraction rato and venc-areil pCO2 ‘ference (ooking for taaue hypopertusion and aeobilanaerble metsbolm) and rally eo. Passive Lg Raising test to assess uid responsiveness, thinking to Frank Siang Curve, Vigorous tid eplacoment fo alate tssuo portion and kdnoy funtion is one possible therapy, only after one goal has boon obains I stat earbonate and fomeplzoe Aternatvely tena replacement therapy is my soliton hat wepynar | Sse Debs Nore alcohol intoxication ABC suport hyeeation thiamine ‘omipizcle heamotaysis (CHRISTOPHER JOHNSON, MD | Pysian- EVERGENCY MEDICINE |Dbcbste. Nave Lime coMPron (ner 29,2018 Woods lamp put the woods lamp tothe wine ane based on urescence properties, aggressively esusciate with IVF, bleatbonate, SP. Within hours e'l be tuned up and ip op for transfert the mental wat... Then ta eal challange fs the root cause othe daconsnuctveness and depressive ius, CONTENT: Home [Caro es | ts sb nce] Secs Tepes [Ribas & nage |v 182-589 INFORMATION FOR: AuPors| Rovowes | uosrbes [rons] Mex [Avetsrs SERVES: Sutecte| Renz [Pay Sl AcateSbsciton | Crele a Warage Aout Aes] RSS A Peal Suma arse Mate RESOURCES: Prysiin Job | Rots | Porn | Modes! Meats |Coertons| FAQS | NIM Knooe+ [NEM Jura Nac | al [Cant Ur tp two jm oaldostry10,t0S6feature 2014 1021.32 18‘weno Neun Nea: Anu | Prt frm | ters & Poke | 200 Bonaray| Ter Us | racy Paley | Cpr aera Pelee NE ‘ME: Weety CME Pagan] Sons Weck Exans| You CME Ay Pucase Exams | Revow GME Program rou ED bp stworw jm oaldostry10,10S6feature 2014. 1021.32 QuM,