LIM, Krizia Marie T.

Level I Medical Resident

ABG Conference (May 2019)

A 28 year old woman with acquired immunodeficiency syndrome (CD4 T cells<10/mM3) and opportunistic
infections (prior cerebral toxoplasmosis and Pneumocystis carinii pneumonia) was admitted due to severe
dyspnea and chest pain. Labs on admission were as follows: BUN 27 mg/dl, Creatinine 1.2 mg/dl, Sodium
138 mEq/L, K 4.1 mEq/L. An initial CXR revealed bilateral pleural effusions and massive cardiomegaly.
Echocardiography demonstrated a large pericardial effusion and a pericardiotomy with window was
performed on the first hospital day. Patient improved, with relief of respiratory distress but remained
febrile. On the second hospital day, Pentamidine was administered. On the 4th hospital day, the
chemistries were as follows: BUN 72 mg/dL, serum crea 2.7 mg/dL, Na 139 mEqL, K 6.8 mEq/L, CI 111
mEq/L, bicarbonate 13 mEq/L, serum osmolality 307 mOsm/Kg H20 and was referred to Nephrology
service. Patient was seen awake, tachypneic, BP 90/60, CR 100, RR 30, T 38.0C, no neck vein distention,
decreased breath sound bibasal, no peripheral edema. ABG was done revealing pH 7.24, pCO2 24,
bicarbonate 10, The following urinary chemistries were obtained at that time: Na 40 mEq/L, K 49 mEq/L,
CI 32mEq/L, crea 79 mg/dL and osmolality 419 mOsm/KgH20.

Guide Questions:
1. What is the acid base problem and electrolyte abnormality and how was it caused?
- Diagnostic clues
o Sepsis (fever, tachypnea, pneumonia) – metabolic acidosis
o Uremia (increased creatinine, BUN) – metabolic acidosis
o Pentamidine (inhibits ENaC, causes hypokalemia) – metabolic acidosis
o Hyperkalemia – metabolic acidosis
o AIDS (adrenal insufficiency/hypoaldosteronism) – metabolic acidosis
o Tachypneic – respiratory alkalosis
- Verify the accuracy of the ABG results
o Modified Henderson Hasselbach equation: 24 x 24/10 = 57.6 -> pH 7.20 - 7.25
- Primary or dominant disorder
o Metabolic ACIDOSIS
- Check the compensatory response
o Change in HCO3 = 24- 13 = 11
o Expected change in PCO2 = 11 x 1.2 = 13.2
o Expected PCO2 = 26.8 +/- 4 = 22.8 to 30.8 (Patient’s PCO2 is 24 mmHg) =
COMPENSATED
- Calculate the anion gap
o AG = Na - (Cl + HCO2)
o AG = 139 - (111 + 13) = 15 +/- 4 (HIGH ANION GAP)
- Use delta/deltas when applicable
o AG/HCO3 = 15-12/24-13 = 0.27 (<1 so HAGMA plus NAGMA)
- IMPRESSION: Partially Compensated Combined High and Normal Anion Gap Metabolic
Acidosis, multifactorial secondary to 1) Lactic acidosis from sepsis 2) Hyperkalemic Renal
Tubular Acidosis secondary to Pentamidine use, cannot totally rule out adrenal insufficiency
from AIDS
2. What other laboratory tests would you do?
- Early morning serum cortisol and plasma ACTH to determine if the patient is having adrenal
insufficiency
- CBC, Serum magnesium and iCa
- Repeat CXR
3. How would you manage this case?