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Case report n°2 Metabolic disorder

Case report n°2 Metabolic disorder. A&E medical meeting 22/02/2012. Presentation: American male 63 years. Past medical history: diabetes type 2 treated by Metformin 200mg x 2 Past surgical history: Colon cancer operated 1 year ago followed by chemiotherapy

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Case report n°2 Metabolic disorder

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  1. Case report n°2Metabolic disorder A&E medical meeting 22/02/2012

  2. Presentation: American male 63 years • Past medical history: diabetes type 2 treated by Metformin 200mg x 2 • Past surgical history: Colon cancer operated 1 year ago followed by chemiotherapy • Current history: vomiting (2-3/day) and diarrhea (9/day) for 6 days, no fever.

  3. Physical examination • General status: asthenia ++, but normal consciousness, no neurodeficit  • Cardio. exam:regular, no abnormal murmur, no sign of cardiac failure   • Pulmo. exam: clear , no rale, no evident dyspnea, no crackles at the bases • Abdo. exam: soft , no local pain , no organomegaly , B.sound increasing +++ • Dehydration +/- • Legs: no edema.

  4. Diagnosis hypothesis ? • What kind of acido-basic disorder is-it? • What is the origin of this acido-basic disorder? • Which biologic test (or calculation) could you ask to have a more accurate analysis? • What are the possible origins of this severe renal failure? • What is in favor of acute/chronic renal failure?

  5. Abdominal ultrasound • The liver is normal in size. Its borders are regular. Its structure is hyperechoic. No focal lesion seen.  • The gallbladder is anechoic. Its wall is not thickened. The bile ducts are not dilated.  • Normal portal flow.  • The spleen, the pancreas demonstrate no abnormality.  • The kidneys are normal in size (right=110x51x74mm, left = 120x52x57mm). No renal stone detected. No hydronephrosis noted.  • Absence of ascites. No pleural effusion.  • No suspicious lymphadenopathy.  • The urinary bladder is anechoic with regular borders • The prostate measures 35x48x35mm=30.5ml (normal < 30ml).

  6. Renal failure analysis • Creat about 600micmol/l > Clearence 16ml/min (Cokroft formula) • Kidneys normal size • No anemia (Hb 12.4g) • No hypercalcemia (1.98mmol/l) Conclusion: Fonctional Acute Renal failure due to dehydration (vomiting & diarrhea) + Metformin treatment

  7. Acido-basic disorder • pH 7.24 with pCO2 25mmHg & Bicar 11mmol/l • Metabolic acidosis (Bicar ↓ & pCO2 ↓) • Anion gap: The term anion gap represents the concentration of all the unmeasured anions in the plasma (ex: Lactates, ketonic, ethanol etc…) Anion Gap* = Na – (Cl + HCO3) * Normal 12+/-2 mmol/l

  8. Different kind of lactic acidosis

  9. Anion gap calculation • Anion Gap = Na –(Cl + HCO3) • Anion Gap = 131 – (101 +11) = 19mmol/l Anion Gap slightly increased 19mmol/l(normal 12 +/-2mmol/l) Lactate dosage: 0.96mmol/l (normal 0.63 – 2.44mmol/l) This is not a lactic acidosis under Metformin…

  10. Anion Gap increased AnionGap normal

  11. How to analyze a metabolic acidosis • Recognize the metabolic acidosis (pH<7.35 with HCO3 ↓) • Calculate the “Anion Gap” to know if this acidosis is due to accumulation of acid (Anion Gap increased) or a loss of base (Anion Gap normal) • Look for the origin of the disorder (see table before)

  12. Evolution in ICU

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