Back to Basics: The Limits of pH Bruce Kaufman, DO/MPH; Justine Hum, MD; Sami Amjad, MD; Jeffrey Gold, MD Department of Medicine, Oregon Health & Science University

Introduction Hospital Course [ ] Discussion ! Metabolic alkalosis occurs due to decreased ! Extreme metabolic alkalosis (EMA) is ! Severe hypokalemia, hypochloremia, and metabolic alkalosis were noted bicarbonate excretion, an increase in on initial chemistries and ABG. rarely encountered acid-base bicarbonate production, or H+ ion loss.1 1 disturbance with a high mortality rate. Diuretic use and loss of chloride-rich ! Intravenous potassium and fluid resuscitation were initiated. Three liters gastric acid are common etiologies.1,2 ! Optimal management is challenging of normal saline were given to attempt induction of a hyperchloremic Development of a New Practice Model and the upper limit of human pH metabolic acidosis and correct the profound hypochloremia. ! EMA is typically characterized by tolerance The Pre-Operative remains Medicine controversial. Clinic (PMC) at OHSU is [ ] neuromuscular irritability, hypoventilation, [ ] in X we embarked… ! Shortly thereafter, the patient became unresponsive and was found to have seizures, and fatal cardiac arrhythmias Case Presentation pulseless electrical activity. associated with a markedly elevated serum 2 HPI: bicarbonate. ! A 47-year-old female with metastatic ! Return of spontaneous circulation was achieved after one round of CPR ! Assessment of volume status and without defibrillation and she was neurologically intact. ovarian cancer complicated by a small hypochloremia guide the decision to trial bowel obstruction received a palliative intravenous fluid replacement.1,2 venting gastrostomy tube. ! Nephrology was consulted and the decision to initiate corrective intravenous acid therapy was made. Hydrochloric acid was unavailable on ! Rare cases of survival have been ! She presented to the Emergency Room hospital formulary; thus, arginine hydrochloride infusion, 150 mEq over 30 documented in patients presenting with an one week later with intractable nausea minutes, was initiated. arterial pH approximating 7.9.2,3 and vomiting and reported severe . anxiety and diffuse muscle spasms. ! Multiple doses of lorazepam and fentanyl were simultaneously ! Alkalosis severity correlates strongly with administered to address the respiratory alkalosis caused by the patient’s prognosis; mortality is nearly 45% when Past Medical History: anxiety and atypical hyperventilation. arterial pH exceeds 7.55 and 80% when the ! BRCA1+ metastatic ovarian cancer pH exceeds 7.65.1 s/p hyperthermic intraperitoneal ! After six hours of acid infusion, repeat venous blood gas analysis noted chemotherapy Teaching Points pH=7.48, pCO2=63 mmHg, and bicarbonate=47 mmol/L. A repeat ! Malignant small bowel obstruction chemistry demonstrated normalization of her potassium to 4.6 mmol/L. ! Assessment for and correction of ! Pelvic deep vein thrombosis underlying hypovolemia is essential to EMA treatment. Past Surgical History: Clinical Follow Up ! Total abdominal hysterectomy/ ! Intravenous acid Referencestherapy is a safe and [ ] ! After our patient’s metabolic bilateral salpingo-oophorectomy effective adjunctive method to correct derangements were stabilized, 1. [ ] ! Omentectomy EMA. Its use is warranted if end-organ additional history revealed she had manifestations are observed and rapid Vitals/Exam: misunderstood her previous reversal is desired. ! Afebrile, HR 89, BP 78/47, RR 22, discharge instructions and vented SpO2 100% on room air. her gastrostomy tube up to five ! Effective patient-physician ! Anxious-appearing cachectic times daily before readmission. communication remains one of the most Caucasian female, hyperventilating, crucial but underutilized means of diffusely tremulous. Cardiopulmonary ! Subsequently, palliative care was prevention. exam WNL. LUQ vented G-tube site consulted and our patient was non-tender and non-erythematous. discharged from the hospital two References Labs: days later on home hospice. 1. Soifer JT, Kim HT. Approach to Metabolic Alkalosis. Emergency Medicine Clinics of North America. May 2014; 32(2):453-63 Initial ABG: 2. Tugrul S, Telci L, Yildirim A, et al. Case report of severe metabolic alkalosis: life-compatible new level. The Journal of Trauma. March 146 81 29 ! pH=7.89, pCO =35 2010; 68(3):E61-3. 139 2 1.9 >45 1.2 mmHg, HCO =67 mmol/L 3. Betten DP, Bridger DJ, Felton BM. Profound alkalemia secondary to 3 gastric outlet obstruction and acute renal insufficiency. The American Journal of Emergency Medicine. February 2013; 31(2):444e1-3