Case report n°2Case report n°2Metabolic disorderMetabolic disorder

A&E medical meetingA&E medical meeting

22/02/201222/02/2012

Presentation: American male 63 yearsPresentation: American male 63 years

Past Past medical history: diabetes type 2 medical history: diabetes type 2

treated by Metformin 200mg x 2treated by Metformin 200mg x 2

Past surgical history: Colon cancer Past surgical history: Colon cancer

operated 1 year ago followed by operated 1 year ago followed by

chemiotherapychemiotherapy

Current history: vomiting (2-3/day) and Current history: vomiting (2-3/day) and

diarrhea (9/day) for 6 days, no fever.diarrhea (9/day) for 6 days, no fever.

PhysicPhysical examinational examination

General status: asthenia ++, but normal General status: asthenia ++, but normal consciousness, no neurodeficit  consciousness, no neurodeficit 

Cardio. exam:regular, no abnormal murmur, no Cardio. exam:regular, no abnormal murmur, no sign of cardiac failure   sign of cardiac failure  

Pulmo. exam: clear , no rale, no evident dyspnea, Pulmo. exam: clear , no rale, no evident dyspnea, no crackles at the bases no crackles at the bases

Abdo. exam: soft , no local pain , no Abdo. exam: soft , no local pain , no organomegaly , B.sound increasing +++ organomegaly , B.sound increasing +++

Dehydration +/- Dehydration +/-

Legs: no edema. Legs: no edema.

DiDiaagnosis gnosis hypothesis ?hypothesis ?

What kind of acido-basic disorderWhat kind of acido-basic disorder is is-it?-it?

What is the origin of this acido-basic disorder?What is the origin of this acido-basic disorder?

Which biologic test (or calculation) could you Which biologic test (or calculation) could you

ask to have a more accurate analysis?ask to have a more accurate analysis?

What are the possible origins of this severe What are the possible origins of this severe

renal failure?renal failure?

What is in favor of acute/chronic renal failure?What is in favor of acute/chronic renal failure?

Abdominal ultrasoundAbdominal ultrasoundThe liver is normal in size. Its borders are regular. Its The liver is normal in size. Its borders are regular. Its structure is hyperechoic. No focal lesion seenstructure is hyperechoic. No focal lesion seen. . The gallbladder is anechoic. Its wall is not thickened. The The gallbladder is anechoic. Its wall is not thickened. The bile ducts are not dilated. bile ducts are not dilated. Normal portal flow. Normal portal flow. The spleen, the pancreas demonstrate no abnormality. The spleen, the pancreas demonstrate no abnormality. The kidneys are normal in size The kidneys are normal in size (right=110x51x74mm, left (right=110x51x74mm, left = 120x52x57mm).= 120x52x57mm). No renal stone detected. No No renal stone detected. No hydronephrosis noted. hydronephrosis noted. Absence of ascites. No pleural effusion. Absence of ascites. No pleural effusion. No suspicious lymphadenopathy. No suspicious lymphadenopathy. The urinary bladder is anechoic with regular bordersThe urinary bladder is anechoic with regular bordersThe prostate measures 35x48x35mm=30.5ml The prostate measures 35x48x35mm=30.5ml (normal < 30ml).(normal < 30ml).

ReRenal failure analysis nal failure analysis

Creat about 600micmol/l > Clearence 16ml/min Creat about 600micmol/l > Clearence 16ml/min (Cokroft formula)(Cokroft formula)

Kidneys normal sizeKidneys normal size

No anemia (Hb 12.4g)No anemia (Hb 12.4g)

No hypercalcemia (1.98mmol/l)No hypercalcemia (1.98mmol/l)

Conclusion:Conclusion:

Fonctional Acute Renal failure due to dehydration Fonctional Acute Renal failure due to dehydration (vomiting & diarrhea) + Metformin treatment(vomiting & diarrhea) + Metformin treatment

Acido-basic disorderAcido-basic disorder

pH 7.24 with pCOpH 7.24 with pCO22 25mmHg & Bicar 11mmol/l 25mmHg & Bicar 11mmol/lMetabolic acidosisMetabolic acidosis (Bicar ↓ & pCO2 ↓) (Bicar ↓ & pCO2 ↓)Anion gap: Anion gap: The term The term anion gapanion gap represents represents the concentration of all the unmeasured the concentration of all the unmeasured anions in the plasma anions in the plasma (ex: Lactates, ketonic, (ex: Lactates, ketonic, ethanol etc…)ethanol etc…)

Anion Gap* = Na – (Cl + HCO3)Anion Gap* = Na – (Cl + HCO3)

* * Normal 12Normal 12+/-2+/-2 mmol/l mmol/l

Different kind of lactic acidosisDifferent kind of lactic acidosis

Anion gap calculation Anion gap calculation

Anion Gap = Na –(Cl + HCO3)Anion Gap = Na –(Cl + HCO3)

Anion Gap = 131 – (101 +11) = Anion Gap = 131 – (101 +11) = 19mmol/l19mmol/l

Anion Gap slightly increased 19mmol/l (normal 12 +/-2mmol/l)

Lactate dosage: 0.96mmol/l (normal 0.63 – 2.44mmol/l)

This is not a lactic acidosis under Metformin…

Anion Gap increased

Anion Gap normal

How to analyze a metabolic acidosisHow to analyze a metabolic acidosis

1.1. Recognize the metabolic acidosis Recognize the metabolic acidosis

(pH<7.35 with HCO3 ↓)(pH<7.35 with HCO3 ↓)

2.2. Calculate the “Anion Gap” to know if this Calculate the “Anion Gap” to know if this

acidosis is due to accumulation of acid acidosis is due to accumulation of acid

(Anion Gap increased) or a loss of base (Anion Gap increased) or a loss of base

(Anion Gap normal)(Anion Gap normal)

3.3. Look for the origin of the disorder (see Look for the origin of the disorder (see

table before)table before)

Evolution in ICUEvolution in ICU

6/02 6/02 (6h00)(6h00) 6/02 6/02 (23h00)(23h00) 7/2 7/2 (6h00)(6h00)

pHpH 7.247.24 7.287.28 7.297.29

pCO2 pCO2 (mmHg)(mmHg) 2525 25.525.5 3030

Bicar Bicar (mmol/l)(mmol/l) 1111 11.911.9 14.414.4

Base ExcessBase Excess -16-16 -15-15 -12-12

CreatCreat (micmol)(micmol) 598598 396396 311311