Published in:
01-01-2005 | Correspondence
Exceptional nonfatal metabolic alkalosis (blood base excess +48 mEq/l)
Published in: Intensive Care Medicine | Issue 1/2005
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Sir: We report a case of extreme metabolic alkalosis resolved by replacement therapy, without aggressive emergency treatments. A 72-year-old woman had a 3-week history of vomiting from duodenal obstruction (cancer of the gallbladder). She was lethargic, with slow eye photomotor reflexes, upon arousal was confused, with poorly coordinated movements and speech, and was malnourished, dehydrated, and oliguric (Table 1). The picture reflected severe chloride-potassium-fluid depletion with metabolic alkalosis, compensatory hypoventilation, hypercapnia, and hypoxemia. Vital signs were stable, emergency treatments were avoided. Under careful monitoring, replacement therapy began by infusing normal saline, potassium and sodium chloride, 5%-dextrose, and an H2 receptor blocker. Under Venti-Mask-O2, PaO2 increased, and PaCO2 increased slightly then decreased. As magnesium, calcium, and phosphate fell, infusions included these electrolytes (with vitamins, trace-elements, nutritional support). The patient condition improved continuously together with blood values (Table 2). Due to transient polyuria and persistent nasogastric losses, up to 7500 ml/day fluids, with 200 mEq/day potassium by pump, were needed. Full stabilization was achieved, and the patient underwent a gastro-jejunostomy followed by uneventful postoperative recovery.
Table 1
Data upon admission
|
Body weight (kg)
|
54
|
|
Height (cm)
|
172
|
|
Actual to ideal body weighta
|
0.83
|
|
Blood pressure (mmHg)
|
120/70
|
|
Heart rate (beats/min)
|
94
|
|
Respiratory rate (shallow breaths/min)
|
30
|
|
Electrocardiography
|
Normal
|
|
Chest radiography
|
Normal
|
|
Arterial blood, room air
|
|
|
O2 tension, PaO2 [mmHg (kPa)]
|
46.7 (6.23)
|
|
CO2 tension, PaCO2 [mmHg (kPa)]
|
69.0 (9.2)
|
|
pH, pHa
|
7.622
|
|
Base excess (mEq/l)b
|
48.0
|
|
CO2 concentration [ml/dl (mmol/l)]c
|
151.2 (67.9)
|
|
Venous plasma
|
|
|
Chloride, Cl− (mEq/l)
|
54
|
|
Potassium (mEq/l)
|
2.2
|
|
Sodium (mEq/l)
|
132
|
|
Calcium [mg/dl (mmol/l)]
|
8.7 (2.2)
|
|
Magnesium [mg/dl (mmol/l)]
|
1.8 (0.7)
|
|
Phosphate [mg/dl (mmol/l)]
|
2.4 (0.8)
|
|
Creatinine [mg/dl (μmol/l)]
|
2.3 (203.3)
|
|
Albumin (g/dl)
|
2.6
|
|
Zinc [γ/dl (μmol/l)]
|
37 (5.7)
|
Table 2
Results of least square regression analyses estimating approximately time sequence of changes in Cl− and base excess (regressions 1 and 2, time ≥1, hours) and the relationship between changes in Cl−, base excess, plasma bicarbonate (HCO3−, mEq/l), PaCO2, and CaCO2 (regressions 3–6). Measurements from admission to day 7 (n= 14, p<0.01 for all)
|
|
Equation
|
R 2
|
|
|---|---|---|---|
|
1
|
Cl−
|
55+11(logn time)
|
0.92
|
|
2
|
Base excess a
|
50 [e−0.02 (time)]
|
0.94
|
|
3
|
Base excess a
|
−0.80 (Cl−) + 95.5
|
0.94
|
|
4
|
HCO3− a
|
−0.86 (Cl−) + 124.8
|
0.93
|
|
5
|
PaCO2
|
−0.85 (Cl−) + 130.7
|
0.85
|
|
6
|
CaCO2 b
|
−1.85 (Cl−) + 265.3
|
0.93
|