1/15 Hey #medtwitter! Have you caught our latest case for the month of April??Check it out 👉🏼
renalfellow.org/2021/04/23/ske…
🏁🏁Let’s Fill in the Gap together with a #tweetorial !
#NMSC #Nephtwitter #FOAMED @TheskeletonKG @NSMCInternship
#covid19 #acidbase
renalfellow.org/2021/04/23/ske…
🏁🏁Let’s Fill in the Gap together with a #tweetorial !
#NMSC #Nephtwitter #FOAMED @TheskeletonKG @NSMCInternship
#covid19 #acidbase
2/15
A 50-year-old man with DM on oral medications presented with respiratory distress and shock. He was diagnosed with #COVID-19 and ARDS requiring intubation. Labs are shown below 👇🏼
🤔🧐
🛑What would be your next step❓❓❓
A 50-year-old man with DM on oral medications presented with respiratory distress and shock. He was diagnosed with #COVID-19 and ARDS requiring intubation. Labs are shown below 👇🏼
🤔🧐
🛑What would be your next step❓❓❓
3/15 You order an ABG:
ABG:
pH 7.14
pCO2 38.8 mmHg
pO2 80 mmHg
Bicarbonate: 16 mmol/L
My Approach:
⚡️pH acidemic or alkalemic ?
⚡️pCO2 respiratory or metabolic?
nephsim.com/acid-base/ h/t @jadav_md for the infographic
ABG:
pH 7.14
pCO2 38.8 mmHg
pO2 80 mmHg
Bicarbonate: 16 mmol/L
My Approach:
⚡️pH acidemic or alkalemic ?
⚡️pCO2 respiratory or metabolic?
nephsim.com/acid-base/ h/t @jadav_md for the infographic
4/15
My Approach Cont:
⚡️Respiratory Compensation? Expected PCO2 = [(1.5 x HCO3-) + 8 ] +/- 2
Anion Gap = Na - (Cl + HCO3-)
⚡️Delta Ratio: ΔAG/ΔHCO3- (18-12)/(24-16) = 0.8
🛑What is the primary acid base disorder? 🤔🧐
My Approach Cont:
⚡️Respiratory Compensation? Expected PCO2 = [(1.5 x HCO3-) + 8 ] +/- 2
Anion Gap = Na - (Cl + HCO3-)
⚡️Delta Ratio: ΔAG/ΔHCO3- (18-12)/(24-16) = 0.8
🛑What is the primary acid base disorder? 🤔🧐
5/15 What is AG?⚡️⛈️
📍Introduced in 1939 as “Gamblegram"
📍law of electro-neutrality states: positive charge (Na+ K + others) = negative charge(Cl+ HCO3+others)
📍During disease, unmeasured anions are formed. Ex: ketoacids, lactic.
Can you have low AG?
📍Introduced in 1939 as “Gamblegram"
📍law of electro-neutrality states: positive charge (Na+ K + others) = negative charge(Cl+ HCO3+others)
📍During disease, unmeasured anions are formed. Ex: ketoacids, lactic.
Can you have low AG?
6/15
Yes!
⭐ Albumin accounts for 80% of AG!
⭐ Low albumin can ⬇ AG and mask HAGMA.
⭐ Don’t be fooled: Always correct for albumin!
⭐ IgG is a cation. can cause low or even negative anion gap. Think paraproteinemia!
⭐ IgA is anionic and ⏫the gap.
Yes!
⭐ Albumin accounts for 80% of AG!
⭐ Low albumin can ⬇ AG and mask HAGMA.
⭐ Don’t be fooled: Always correct for albumin!
⭐ IgG is a cation. can cause low or even negative anion gap. Think paraproteinemia!
⭐ IgA is anionic and ⏫the gap.
9/15 🧐🤔
Hypothesis 1:
⭐ HAGMA may be driven by the high propofol infusion rates, manifesting as propofol infusion syndrome (PRIS)
⭐ Respiratory acidosis is likely due to the ongoing COVID infection.
🛑Propofol is stopped, bicarbonate infusion is started
Hypothesis 1:
⭐ HAGMA may be driven by the high propofol infusion rates, manifesting as propofol infusion syndrome (PRIS)
⭐ Respiratory acidosis is likely due to the ongoing COVID infection.
🛑Propofol is stopped, bicarbonate infusion is started
10/15
Day 4 labs: post propofol and on bicarbonate.
🛑 What is the acid-base disorder???
Day 4 labs: post propofol and on bicarbonate.
🛑 What is the acid-base disorder???
11/15
Yes! 🎉🥳🪅
⭐patient now has a wider HAGMA + Respiratory Acidosis
⭐BHB now increased to 6 from 2.9 mmol/l, BG 180-210 mg/dl
⭐Euglycemic ketoacidosis.
🛑What home medication do you look for?
Yes! 🎉🥳🪅
⭐patient now has a wider HAGMA + Respiratory Acidosis
⭐BHB now increased to 6 from 2.9 mmol/l, BG 180-210 mg/dl
⭐Euglycemic ketoacidosis.
🛑What home medication do you look for?
12/15
Yes,SGLT2i! On review of home meds patient on ⚡️ empagliflozin⚡️
What is EDKA?
⭐ADA defines DKA as BG >250 mg/dl, acidosis pH <7.3, bicarbonate <15
⭐Think EDKA when BG <250 and ☝️
⭐Munro et al. described ketoacidosis with "normoglycemia" on review of 211 cases.
Yes,SGLT2i! On review of home meds patient on ⚡️ empagliflozin⚡️
What is EDKA?
⭐ADA defines DKA as BG >250 mg/dl, acidosis pH <7.3, bicarbonate <15
⭐Think EDKA when BG <250 and ☝️
⭐Munro et al. described ketoacidosis with "normoglycemia" on review of 211 cases.
13/15
How do SGLT2 inhibitors cause EDKA?
⭐Inhibits receptors in the pancreatic a-cells. ⬆️ glucagon, ⬆️Fatty acid metabolism.
⭐Interferes with proximal tubule ATP consumption causing ⬇️ ammoniagenesis, ⬆️ fat oxidation+bicarb loss
⭐ See VA for a fantastic review!
How do SGLT2 inhibitors cause EDKA?
⭐Inhibits receptors in the pancreatic a-cells. ⬆️ glucagon, ⬆️Fatty acid metabolism.
⭐Interferes with proximal tubule ATP consumption causing ⬇️ ammoniagenesis, ⬆️ fat oxidation+bicarb loss
⭐ See VA for a fantastic review!
14/15 Take Home
⚡️ABG approach
⛈️PRIS can cause HAGMA by inhibiting ETC.
⚡️Think EDKA BG<250, ketosis, unexplained acidosis.
⛈️risk factors for euglycemic DKA include starvation, SGLT2i use, pancreatitis
check out this fantastic blogpost by @priti899: renalfellow.org/2020/09/08/sgl…
⚡️ABG approach
⛈️PRIS can cause HAGMA by inhibiting ETC.
⚡️Think EDKA BG<250, ketosis, unexplained acidosis.
⛈️risk factors for euglycemic DKA include starvation, SGLT2i use, pancreatitis
check out this fantastic blogpost by @priti899: renalfellow.org/2020/09/08/sgl…
15/15 Amazing VA @hellokidneyMD summarizes the case! Read full post at @RenalFellowNtwk for more twists and turns!
renalfellow.org/2021/04/23/ske…
Thank you to @brian_rifkin @jadav_md @DTomacruzMD @kkalra_22
renalfellow.org/2021/04/23/ske…
Thank you to @brian_rifkin @jadav_md @DTomacruzMD @kkalra_22
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