1/ #UncleBob is so proud if his former intern, now excellent ICU attending! #5goodminutes on this patient
Let's start with the acid-base status.
2/ The ABG clearly shows respiratory alkalosis. I suspect it is secondary to oxygen stimulus. The patient has a huge A-a gradient (suspect secondary to her IHD). Suspect she is volume overloaded & due to ESRD the only way to correct her volume would be dialysis. Call renal
3/ We can probably explain the mildly low Na from the hyperglycemia - will not spend more time on that. Would love an albumin for 2 reasons - to assess her anion gap and the decreased Calcium. Suspect it is low and her gap is even more significant than it appears.
4/ Would love to know her more recent basic metabolic panel. Has she had a previous Echo? What is her weight compared to her usual (dialysis center should keep track of that)?
Would check the QT interval on the EKG - is the calcium really low? Maybe an ionized calcium
5/ Would continue insulin until gap resolves - might check both lactic acid and serum ketones to better establish her anion gap. Would also check phosphate - often increased in ESRD - can give an anion gap of this size.
6/ Would it hurt to increase her FiO2? She is clearly hyperventilating to maintain her O2 sat. Normally we would not do that, but the hyperventilation and alkalosis are very concerning.
I hope this is helpful.
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