A 65-year-old male has been brought into the Emergency Department after being found unconscious at home. He has a heart rate of 87 beats/min, a blood pressure of 96/59 mmHg, and temperature of 31.2°C.
Below is his biochemical profile and arterial blood gas analysis on a Hudson mask delivering 6 L/min oxygen:
Arterial Blood Gas:
Parameter |
Patient Value |
Normal Adult Range |
pH |
7.07* |
7.35 – 7.45 |
PaO2 |
59 mmHg (7.8 kPa)* |
|
PaCO2 |
25 mmHg (3.3 kPa)* |
35 – 45 (4.6 – 6.0) |
Bicarbonate |
7 mmol/L* |
22 – 26 |
Base Excess |
-22 mmol/L* |
-2 – +2 |
Lactate |
0.8 mmol/L |
< 2.0 |
Venous Biochemistry: |
||
Parameter |
Patient Value |
Normal Adult Range |
Sodium |
133 mmol/L* |
135 – 150 mmol/L |
Potassium |
6.2 mmol/L* |
3.4 – 5.0 |
Chloride |
94 mmol/L* |
100 – 110 |
Urea |
25.9 mmol/L* |
3.0 – 8.0 |
Creatinine |
271 mmol/L* |
50 – 120 |
Total Bilirubin |
13 mmol/L |
< 20 |
Albumin |
42 G/L |
35 – 50 |
Alanine Aminotransferase |
360 U/L* |
< 35 |
Aspartate Aminotransferase |
612 U/L* |
< 40 |
g-Glutamyl Transferase |
52 U/L* |
< 40 |
Alkaline Phosphatase |
123 U/L |
35 – 135 |
Creatine Kinase |
335 U/L* |
30 – 140 |
Calcium (corrected) |
2.65 mmol/L* |
2.15 – 2.60 |
Magnesium |
1.52 mmol/L* |
0.7 – 1.10 |
Phosphate |
3.91 mmol/L* |
0.8 – 1.50 |
Glucose |
10.5 mmol/L* |
3.0 – 5.4 |
Ketones |
6.6 mmol/L* |
< 0.5 |
a) Describe the acid-base abnormalities seen in the arterial blood gas analysis.
b) List three possible causes of the ketosis.
c) What is the most likely cause? Give your reasoning.
a) High anion gap metabolic acidosis (ketones and other unmeasured anion). Respiratory acidosis / inadequate respiratory compensation.
b) Alcoholic ketosis. Diabetic (euglycaemic) ketoacidosis. Starvation ketosis.
c) Alcoholic ketosis. Combination of severe AG acidosis with high level of ketones (too high for starvation ketosis) and abnormal liver enzymes (less likely with DKA).
Let us dissect these results systematically.
The lactate cannot account for this, and the renal failure - though severe - is insufficiently severe to serve as an explanation for such a raised anion gap. Ketones remain as the only explanation.
The college asks for three differentials for ketosis, which is helpful (because there only three major types):
Ketoacidosis mechanisms and management strategies for DKA are discussed elsewhere.
This patient is probably a veteran drinker. As the college points out, starvation ketoacidosis does not tend to have such a high ketone level, and DKA patients are unlikely to have such abnormal LFTs.
UpToDate has a nice summary of this topic for the paying customer.
Oh's Intensive Care manual: Chapter 58 (pp. 629) Diabetic emergencies by Richard Keays
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