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Home | Investigation | Metabolic Mayhem a Headache

Metabolic Mayhem a Headache

by Paul Young, Last updated May 6, 2017

aka Metabolic Muddle 003

An 87 year old female presented with a subarachnoid haemorrhage.  GCS 8/15.  A nasogastric tube was unable to be placed due to patient agitation.  As a consequence, the patient was fasted for five days due to concern about swallowing.

Aan arterial blood gas was subsequently obtained:

Questions

Q1. Describe the arterial blood gas

Answer and interpretation

  1. There is a metabolic acidosis with a high anion gap (HAGMA).
  2. The bicarbonate has decreased by more than the anion gap has increased which is due to a coexistent normal anion gap acidosis (NAGMA).
  3. There is a respiratory alkalosis. The pCO2 of 12mmHg is much lower than the respiratory compensation you would expect with this degree of metabolic acidosis (expected pCO2 = 1.5 * HCO3 +8 = 25 ).

The combination of these three abnormalities has led to relatively normal pH despite severe acid-base disturbance.

—

Q2. What are the causes of metabolic acidosis with raised anion gap and what is the likely cause here?

Answer and interpretation

There are two ways of remembering this.

The easy way is to remember ‘left total knee replacement’:

Lactate
Toxins
Ketones
Renal Failure

The more complicated way is CAT-MUDPILES:

Cyanide, Carbon monoxide
Alcoholic ketoacidosis
Toluene
Methanol, metformin
Uraemia
Diabetic Ketoacidosis
Phenformin, pyroglutamic acidosis, propylene glycol, paracetamol
Isoniazid, Iron
Lactic acidosis (many causes)
Ethanol, Ethylene glycol
Starvation, salicylates

The history suggests starvation ketoacidosis. There were ketones in the urine confirming this diagnosis.

—

Q3. What are the causes of normal anion gap acidosis and what is the likely cause here?

Answer and interpretation

The easy way to remember is OGRe:

Others (eg chloride)
GI loss of bicarb
Renal loss of bicarb

The more difficult way is to remember is USED CARP (the A and the R can be reversed – this is optional):

Ureteroenterostomy
Small bowel fistula
Extra Chloride
Diarrhoea
Carbonic anhydase inhibitors
Addisons disease
Renal tubular acidosis
Pancreatic fistula

Neurosurgeons like to give everyone lots of normal saline. The chloride is high.

The likely diagnosis is hyperchloraemic metabolic acidosis secondary to normal saline.

—

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Filed Under: Investigation Tagged With: Acid Base, arterial blood gases, metabolic acidosis, metabolic muddle, subarachnoid hemorrhage, triple acid base disturbance

About Paul Young

Paul is an Intensivist in Wellington, New Zealand. Although he started out in the ED, Paul now feels physically ill whenever he steps foot on the front line. | + Paul Young |

Reader Interactions

Comments

  1. Chris Nickson says

    March 10, 2011 at 9:33 pm

    USED CARP is rubbish really isn’t it – maybe ABCD is better:
    Addisons
    bicarb loss (GI or renal)
    chloride excess
    drugs (carbonic anhydrase inhibitors)

    C

    Reply
  2. Adam Herbstritt (@apherbie) says

    September 8, 2012 at 10:05 am

    Hi!

    Calculation of the AG (141 – 117 – 11) gives a value of 13. 12 +/-5 seems to be considered normal & not suggesting HAGMA. This leaves NAGMA & resp alkalosis secondary to excess iv saline & CNS pathology respectively. I’d be interested on your thoughts!

    I use Huffed & PUFT for resp alkalosis:

    H hypoxia & [psych] hyperventilation
    P pregnancy
    U ‘uncus’ [tenuous] CNS pathology
    F failures (LVF, liver)
    T toxins (salicylates & sympathomimetics)

    Thanks
    Adam

    Reply
    • Chris Nickson says

      September 8, 2012 at 12:05 pm

      Huffed and PUFT – nice one!
      Chris

      Reply
    • Ellen says

      February 27, 2014 at 1:17 pm

      corrected Na for hyperglycaemia is 142.5 therefore AG 14.5 which tends to be more towards HAGMA

      Reply
      • Chris Nickson says

        February 27, 2014 at 8:55 pm

        Hi Ellen

        Corrected Na should not be used for calculation of the anion gap.

        The anion gap reflects the balance between positively and negatively charged electrolytes in the extracellular fluid. Glucose is electrically neutral and does not directly alter the anion gap. However, glucose is osmotically active so water is pulled into the extracellular fluid. This has a dilutional effect on all extracellular electrolyte concentrations, both positive or negative, and so the anion gap is minimally altered.

        This paper has a more detailed explanation:

        Beck, LH. Should the actual or the corrected serum sodium be used to calculate the anion gap in diabetic ketoacidosis? CLEVELAND CLINIC JOURNAL OF MEDICINE 2001; 68 (8) 673-674.

        http://www.ccjm.org/content/68/8/673.full.pdf

        Cheers
        Chris

        Reply
  3. drdeannechiu says

    August 5, 2015 at 12:30 pm

    I’m using GREED instead of USED CARP. I think of NAGMA as a nagging ma, who only married for the money..

    GI bicarb loss – small bowel losses (fistulae/-ostomy), diarrhoea
    Renal bicarb loss – RTA, ureteric
    Endocrine
    Excess Chloride
    Drugs – Carbonic Anhydrase Inhibitors,

    Reply

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