Morning Report: Approach to the Complicated Metabolic Acidosis

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)

Reference:

• http://fitsweb.uchc.edu/student/selectives/TimurGraham/Delta_Ratio.html
• http://lifeinthefastlane.com/metabolic-muddle-003/

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• Bio
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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

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