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Computer-Based Scenario Biochemistry: How To Read Bloods?
Computer-Based Scenario Biochemistry: How To Read Bloods?
Biochemistry
• None
• Part 1
– Structure of a biochemical case
STRUCTURE OF A BIOCHEMICAL
CASE
URINE or QUESTION
What is the immediate management?
• Diabetic ketoacidosis
• Intravenous crystalloids
• Intravenous insulin
• Consider bicarbonate if K+ not decreasing soon
• ECG and consider i.v. Ca2+
THE VIGNETTE
• Hypermagnesaemia/measure Mg2+
Respiratory disorders
= alkalosis
= acidosis
BE = mM of acid needed to
HCO3- (standard) = return pH to 7.40 under
corrected to pCO2=5.33 kPa
pCO2=5.33kPa BE (B)= blood (actual Hb)
BE (ect)=model of ecf (1/3 of
Hb)
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Problem 1 solved
• HCO3- (actual)
– Influenced by pCO2 (H++HCO3- <-> CO2+H2O)
AG <16 mM=
Hyperchloridaemic MAC = Elevated AG (>16 mM)=
bicarbonate loss find circulating acid
•GI? •Lactate?
•Kidney? •Ketones?
•Too much chloride? •Retained inorganic
acids in AKI?
•Poison?
Other Other
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+≠- +=-
strong anions 5
140 100
Na+
Cl-
14
30
Difference (SIDa-Na_Cl)
12
10
8
20
6
4
0 5 10 15 20 25 30 35 40 45 50 55 60
Average of SIDa and Na_Cl
10
0 10 20 30 40 50
Na-Cl [mmol/L] (Courtesy of Waldauf and Elbers)
• GI bleed?
• Alcoholic hepatitis and liver failure?
• Poisoning (e.g. ethylenglycol, methanol)?
• Other
– Gastroenteritis/food poisoning dehydration
– Non-diabetic ketoacidosis
Sodium 132 mmol/L Arterial Blood Gas. 15 L/min O2 via face mask
Potassium 4.6 mmol/L pH 7.432
Chloride 70 mmol/L pO2 28.3 kPa (212 mmHg)
Ionized Calcium 0.61 mmol/L pCO2 4.81 kPa (36 mmHg)
HCO3- (st) 24.3 mmol/L
Base Excess -0.7 mmol/L
Glucose 8.0 mmol/L 144 mg/dL
Haemoglobin 12 g/dL (120 g/L) Describe acid-base disorder and give possible
causes.
Urine Ketones +
Glucose -
HCO3- 24.3
62
strong anions
There is also METABOLIC
132 ACIDOSIS caused by 22mM of
yet unknown strong anion.
Na+
70
Cl-
1 2 3 4 5
Look at BE
Look at Look at Look at
on blood Summarise
[Na+]-[Cl-] Albumin pCO2
gas
Compare with 10 g/L missing Identify strong If acidosis, it should Use clinical context
34 adds 3mM to ion, lactate be bicarb/5 + 1 kPa to unveil likely
BE and non- pathophysiology
lactate
1 2 3 4 5
Disorders Identify
Disorders
caused by unmeasured Assess pCO2 Summarise
caused by A-
SID anion(s)
1 2 3 4 5
Disorders Identify
Disorders
caused by unmeasured Assess pCO2 Summarise
caused by A-
SID anion(s)
1 2 3 4 5
Disorders Identify
Disorders
caused by unmeasured Assess pCO2 Summarise
caused by A-
SID anion(s)
1 2 3 4 5
Disorders Identify
Disorders
caused by unmeasured Assess pCO2 Summarise
caused by A-
SID anion(s)
Na-Cl=24 mM
HYPERCHLORIDAEMIC
ACIDOSIS
All other values in this patient kept constant (curve created on www.acidbase.org)
Lactate – normal
Ketones – negative
Renal failure ?
Poisons? Osm .gap normal (7 mM)
• D-lactic acidosis
• High AG acidosis/acidosis in AKD
1 2 3 4 5
Look at BE
Look at Look at Look at
on blood Summarise
[Na+]-[Cl-] Albumin pCO2
gas
Compare with 10 g/L missing Identify strong If acidosis, it should Use clinical context
34 adds 3mM to ion, lactate be bicarb/5 + 1 kPa to unveil likely
BE and non- pathophysiology
lactate