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A Patient with Altered Mental Status and an Acid-Base Disturbance

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A Patient with Altered Mental Status and an Acid-Base Disturbance IM BOARD REVIEW A SELF-TEST CME EDUCATIONAL OBJECTIVE: Readers will apply a systematic approach to diagnosing acid-base disturbances ON A CREDIT CLINICAL SHYLAJA MANI, MD GREGORY W. RUTECKI, MD Department of Internal Medicine, Department of Internal Medicine, CASE Cleveland Clinic Cleveland Clinic A patient with altered mental status and an acid-base disturbance 78-year-old black woman with a his- TABLE 1 A tory of osteoarthrosis and chronic diffuse joint pain presents with altered mental status The patient’s laboratory values and tachypnea, which began 3 hours earlier. She lives alone, and her family suspects she Substance Value Reference range abuses both alcohol and her pain medica- Blood chemistry tions. She has not been eating well and has lost approximately 10 pounds over the past 3 Sodium 132 mmol/L 136–144 months. Her analgesic regimen includes acet- Potassium 4.8 mmol/L 3.7–5.1 aminophen and acetaminophen-oxycodone. a In the emergency department her tem- Bicarbonate 16.0 mmol/L 22–30 perature is 98.6°F (37.0°C), pulse 100 beats Chloride 95 mmol/L 97–105 per minute and regular, respiratory rate 22 per minute, and blood pressure 136/98 mm Hg. Blood urea nitrogen 23 mg/dL 7–21 She is obtunded but has no focal neurologic Creatinine 1.3 mg/dL 0.58–0.96 defects or meningismus. She has no signs of heart failure (jugular venous distention, car- Glucose 97 mg/dL 74–99 diomegaly, or gallops), and examination of the Lactate 1.1 mmol/L 0.5–2.2 lungs and abdomen is unremarkable. Suspecting that the patient may have tak- Albumin 4.5 g/dL 3.9–4.9 en too much oxycodone, the physician gives Serum osmolality 318 mOsm/kg 275–295 her naloxone, but her mental status does not improve. Results of chest radiography and cra- Arterial blood gases nial computed tomography are unremarkable. pH 7.25 7.35–7.45 The physician’s initial impression is that the b patient has “metabolic encephalopathy of un- PCO2 28 mm Hg 34–46 known etiology.” Bicarbonate 16 mmol/L 22–26 The patient’s laboratory values are shown in Table 1. aFor acid-base problem-solving, a value of 25 mmol/L is considered normal. b Healthier patients with better pulmonary function may attain lower PCO2 values; for clinical problem-solving, a value of 40 mm Hg is considered normal. ■ WHICH ACID-BASE DISORDER PCO = partial pressure of carbon dioxide DOES SHE HAVE? 2 Which acid-base disorder does this patient □ Metabolic acidosis with an elevated 1have? anion gap □ A triple disturbance: metabolic acidosis, □ Metabolic acidosis and respiratory alkalosis respiratory acidosis, and metabolic □ Metabolic acidosis and respiratory acidosis alkalosis doi:10.3949/ccjm.84a.16042 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 84 • NUMBER 1 JANUARY 2017 27 Downloaded from www.ccjm.org on October 2, 2021. For personal use only. All other uses require permission. ACID-BASE DISTURBANCE TABLE 2 A 5-step approach Acid-base disorders can be diagnosed and ‘Rules of 5’ for acid-base problem-solving characterized using a systematic approach known as the “Rules of 5” (Table 2)1: 1 Determine the arterial pH status 1. Determine the arterial pH status. pH < 7.40 is acidemic, pH > 7.44 is alkalemic 2. Determine whether the primary process is But a normal pH does not rule out an acid-base disorder respiratory, metabolic, or both. 3. Calculate the anion gap. 2 If the arterial pH is abnormal, determine whether 4. Check the degree of compensation the primary process is respiratory, metabolic, or both (respiratory or metabolic). pH PCO2 Bicarbonate 5. If the patient has metabolic acidosis with Respiratory acidosis Low High — an elevated anion gap, check whether the bicarbonate level has decreased as much Metabolic acidosis Low — Low as the anion gap has increased (ie, whether Mixed respiratory and Low High Low there is a delta gap). metabolic acidosis Let us apply this approach to the patient Respiratory alkalosis High Low — described above. Metabolic alkalosis High — High 1. What is her pH status? Mixed respiratory and High Low High An arterial pH less than 7.40 is acidemic, metabolic alkalosis whereas a pH higher than 7.44 is alkalemic. (Acidemia and alkalemia refer to the abnormal 3 Calculate the anion gap laboratory value, while acidosis and alkalosis Anion gap = sodium – (chloride + bicarbonate) refer to the process causing the abnormal val- ue—a subtle distinction, but worth keeping in If serum albumin is low, add 2.5 mmol/L to the anion gap mind.) for every 1 g the serum albumin is below normal Caveat. A patient may have a significant An anion gap > 10 mmol/L is elevated acid-base disorder even if the pH is normal. 4 Check the degree of compensation (respiratory or metabolic) Therefore, even if the pH is normal, one should verify that the partial pressure of car- PCO2 and bicarbonate should move in the same direction bon dioxide (Pco2), bicarbonate level, and an- Nominal normal levels: bicarbonate 25 mmol/L and PCO2 40 mm Hg ion gap are normal. If they are not, the patient may have a mixed acid-base disorder such as In respiratory acidosis, for every 10-mm Hg increase in PCO2, bicarbonate should increase by 1 mmol/L in the first 48 hours respiratory acidosis superimposed on metabol- and 4 mmol/L afterward ic alkalosis. In metabolic acidosis, for every 1-mmol/L decrease in bicarbonate, Our patient’s pH is 7.25, which is in the acidemic range. PCO2 should decrease by 1.3 mm Hg In respiratory alkalosis, for every 10-mm Hg decrease in PCO2, 2. Is her acidosis respiratory, metabolic, bicarbonate should decrease by 2 mmol/L in the first 48 hours or both? and 5 mmol/L afterward Respiratory acidosis and alkalosis affect the In metabolic alkalosis, for every 1-mmol/L increase in bicarbonate, Pco2. The Pco2 is high in respiratory acido- PCO2 may increase by 0.6 mm Hg sis (due to failure to get rid of excess carbon dioxide), whereas it is low in respiratory alka- 5 If the patient has metabolic acidosis with an elevated an- losis (due to loss of too much carbon dioxide ion gap, check whether the bicarbonate level has decreased through hyperventilation). as much as the anion gap has increased Metabolic acidosis and alkalosis, on the In metabolic acidosis, the anion gap should increase by the same other hand, affect the serum bicarbonate lev- amount that bicarbonate decreases; a difference in these two changes is el. In metabolic acidosis the bicarbonate level called a delta gap is low, whereas in metabolic alkalosis the bi- carbonate level is high. PCO = partial pressure of carbon dioxide 2 Moreover, in mixed respiratory and meta- Based on information in reference 1 bolic acidosis, the bicarbonate level can be 28 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 84 • NUMBER 1 JANUARY 2017 Downloaded from www.ccjm.org on October 2, 2021. For personal use only. All other uses require permission. MANI AND RUTECKI low and the Pco2 can be high. In mixed meta- Our patient’s bicarbonate level is 16 bolic and respiratory alkalosis, the bicarbon- mmol/L, which is 9 mmol/L lower than nor- ate level can be high and the Pco2 can be low mal (for acid-base calculations, we use 25 (Table 2). mmol/L as the nominal normal level). If she is Our patient’s serum bicarbonate level is compensating appropriately, her Pco2 should low at 16.0 mmol/L, indicating that the pro- decline from 40 mm Hg (the nominal normal cess is metabolic. Her Pco2 is also low (28 mm level) by about 11.7 mm Hg (9 × 1.3), to ap- Hg), which reflects an appropriate response to proximately 28.3 mm Hg. Her Pco2 is, indeed, compensate for the acidosis. 28 mm Hg, indicating that she is compensat- 3. What is her anion gap? ing adequately for her metabolic acidosis. Always calculate the anion gap, ie, the serum If we use Winter’s formula instead (Pco2 = 3 sodium concentration minus the serum chlo- [1.5 × the bicarbonate level] + 8 ± 2), the ride and serum bicarbonate concentrations. If lowest calculated Pco2 would be 30 mm Hg, the patient’s serum albumin level is low, for which is within 2 mm Hg of the Rules of 5 every 1 gram it is below normal, an additional calculation. Other formulas for calculating 2.5 mmol/L should be added to the calculated compensation are available.3 anion gap. We consider an anion gap of 10 This information rules out the first two an- mmol/L or less as normal. swers to question 1, ie, metabolic acidosis with Caveats. The blood sample used to calcu- respiratory alkalosis or acidosis. late the anion gap should be drawn close in time to the arterial blood gas sample. 5. Is there a delta gap? Although the anion gap is an effective Although we know the patient has metabolic tool in assessing acid-base disorders, further acidosis with an elevated anion gap, we have investigation is warranted if clinical judg- not ruled out the possibility that she may have ment suggests that an anion gap calculation a triple disturbance. For this reason we need to is inconsistent with the patient’s circum- check her delta gap. 2 In metabolic acidosis with an elevated an- stances. The patient Our patient’s anion gap is elevated (21 ion gap, as the bicarbonate level decreases, mmol/L). Her serum albumin level is in the the anion gap should increase by the same lives alone, normal range, so her anion gap does not need amount.
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