A 25-year-old female with a 5-day history of anorexia, nausea and vomiting presents to hospital after a convulsion and is transferred immediately to your ICU. She is G3P2 and 30/40 gestation.The following blood results are obtained:
|Parameter||Patient Value||Adult Normal Range|
|pH||7.54*||7.35 - 7.45|
|p02||87 mmHg (11.6 kPa)|
|pC02||33.0 mmHg (4.4 kPa)*||35.0 - 45.0 (4.6 - 6.0)|
|Bicarbonate||28.0 mmol/L*||22.0 - 26.0|
|Base Excess||4.5 mmol/L*||-2.0 - +2.0|
|Sodium||127 mmol/L*||135 - 145|
|Potassium||2.3 mmol/L*||3.5 - 5.0|
|Chloride||84 mmol/L*||95 - 105|
|Glucose||4.8 mmol/L||3.5 - 6.0|
|Creatinine||354 µmol/L*||45 - 90|
|Urea||29.0 mmol/L*||3.0 - 8.0|
|Haemoglobin||177 g/L*||120 - 160|
|White Cell Count||25.4 x 109/L*||j||4.0 - 11.0|
|Platelet count||29 x 109/L*||I||150 - 350|
|Prothrombin time||15.0 sec||12.0 - 16.5|
|INR||1.1||0.9 - 1.3|
|APTT||28.0 sec||27.0 - 38.5|
|Fibrinogen||5.7 g/L*||,||2.0 - 4.0|
|D-Dimer||16.8 mg/L*||/||< 0.5|
Describe the important metabolic abnormalities and give one explanation for each.
Describe the important abnormalities and give one explanation for each?
- Raised Aa gradient (aspiration, pneumonia, any plausible)
- Metabolic alkalosis -dehydration, vomiting
- Raised anion gap – sepsis, seizures, renal failure
- Respiratory alkalosis- pain, anxiety, post ictal
- Hypokalaemia, hyponatraemia : dehydration
- AKI – sepsis, TTP, dehydration,eclampsia
- Haemoconcentration – dehydration
- Leucocytosis – sepsis
- Thrombocytopenia –sepsis, TTP, HELLP
- Elevated fibrinogen, D-Dimer – sepsis
- The patient is alkalaemic. This pH is in excess of what would normally be expected in pregnancy
- There is normoxia (PaO2 is satisfactory) but the A-a gradient is raised.
- The CO2 is within normal limits for this stage in pregnancy
- Oxygen saturation is lower than would be expected for this level of alkalosis (i.e. there is an unexplained right-shift of the oxyhaemoglobin dissociation curve).
- Base excess and bicarbonate present a metabolic alkalosis. In pregnancy, one would conventionally expect to normally have a lower bicarbonate level because of the chronic respiratory alkalosis. Ergo, in this scenario, the metabolic alkalosis from vomiting and dehydration is even worse than it seems.
- The patient is hyponatremic, though it is not so severe as to produce the seizures. One possible explanation for this is the fluid overload and water retention related to the renal failure.
- Potassium is severely depleted, which is likely related to the nausea and vomiting
- The low chloride is due to the vomiting
- The creatinine and urea are raised, indicating acute kidney injury
- The haemoglobin is significantly higher than would be expected at this stage of pregnancy, which suggests significant dehydration
- The white cell count is elevated, which may be a combination of haemoconcentration and infection
- There is thrombocytopenia, consistent with HELLP - but it could also be consumptive, eg. in the context of thrombosis or something like TTP/HUS.
- The coags are normal, which virtually excludes hepatic involvement
- The D-dimer is elevated, which might represent thrombosis and consumption (of particular interest would be cerebral venous sinus thrombosis).