Critical Care Medicine-Renal, Electrolyte and Acid Base Disorders>>>>>Acid Base Disorders
Question 10#

A 23-year-old man is brought to the hospital by his girlfriend. She states that he has not been feeling well, complaining of nausea and abdominal pain for the past 2 days. His younger sister was recently treated for rotavirus, though she denies that anyone else had any other symptoms. Given his lethargy, he has not taken any of his medications. She also admits that he “binge drinks” on occasion but has not consumed any alcohol over 2 months.

On physical examination:

• his temperature is 36.8°C
• blood pressure is 92/60 mm Hg
• pulse rate is 124 beats/min
• respiratory rate is 10 breaths/min

His oral mucosa is dry, and his pulse is palpable though thready.

Lab results:

• Sodium 132 mEq/L (mmol/L)
• Potassium 4.2 mEq/L (mmol/L)
• Chloride 102 mEq/L (mmol/L)
• Bicarbonate 10 mEq/L (mmol/L)
• Glucose 656 mg/dL
• BUN 42 mg/dL
• Creatinine 1.4 mg/dL
• Albumin 4.1 g/L
• Calcium 9.8 mg/dL

ABG:

• pH 7.48
• pCO₂ 45 mm Hg

Which of the following is MOST likely the cause of his acid-base disturbances?

A. Starvation ketoacidosis
B. Acute kidney injury
C. Alcoholic ketoacidosis
D. d-Lactic acidosis
E. Diabetic ketoacidosis (DKA)

Correct Answer is E

Comment:

Correct Answer: E

Both diabetic and alcoholic ketoacidosis can lead to increased anion gap metabolic acidosis. However, given the patient’s elevated blood glucose and ketones in the urine, this is more suggestive of DKA. Patients with DKA generally present with nausea, vomiting, and abdominal pain. Patients with diabetes can develop DKA due to a reduction in effective insulin leading to increased conversion of free fatty acids into ketones, including β-hydroxybutyrate and acetoacetic acid, thereby leading to ketoacidosis. In this case, the patient’s elevated β-hydroxybutyrate also points toward DKA, though it may not be present in all cases. Treatment includes insulin and fluid administration as most of the patients are volume depleted.

References:

1. Dunger DB, Sperling MA, Acerini CL, et al. ESPE/LWPES consensus statement on diabetic ketoacidosis in children and adolescents. Arch Dis Child. 2004;89:188-194.
2. Viallon A, Zeni F, Lafond P, et al. Does bicarbonate therapy improve the management of severe diabetic ketoacidosis? Crit Care Med. 1999;27(12):2690-2693.