Project introduction :
"Replacement of sodium bicarbonate to patients with sodium bicarbonate loss due to diarrhea or renal proximal tubular acidosis is useful, but there is no definite evidence that sodium bicarbonate administration to patients with acute metabolic acidosis, including diabetic ketoacidosis, lactic acidosis, septic shock, intraoperative metabolic acidosis, or cardiac arrest, is beneficial regarding clinical outcomes or mortality rate. Patients with advanced chronic kidney disease usually show metabolic acidosis due to increased unmeasured anions and hyperchloremia. It has been suggested that metabolic acidosis might have a negative impact on progression of kidney dysfunction and that sodium bicarbonate administration might attenuate this effect, but further evaluation is required to validate such a renoprotective strategy."
Above quoted from :
Case report form for one patient :
Conversational learning around the same patient :
[11/21, 7:42 PM] Moderator :
Log Book assessment: PG Med
Context : An elderly patient with severe anemia, hypotension, severe metabolic acidosis, encephalopathy and recent fracture femur
More :
Impact :
On learning ecosystem :
Cognitive competency levels touched :
Approach to clinical localization of disease pathology was done reasonably well and differential diagnostic hypothesis formulated
On patient care outcomes :
Empathic trust built with patient and relatives
Standard of care provided with provision for care continuity
Challenges met/not met : managing diagnostic arranging of repeating hemoglobin levels, repeat imaging to assess hematoma, continuing dialysis, reviewing the literature around giving bicarbonate in high anion gap metabolic acidosis
[11/21, 7:43 PM] Moderator : 👆How is this patient now? 🤔
[11/21, 7:44 PM] PG Med: Sir he expired at 10 am today ,
[11/21, 7:44 PM] PG Med: https://scholar.google.com/
[11/21, 7:44 PM] PG Med:
Quoting from above link :
Dialysate (HCO3–) prescriptions differ widely throughout the world. About half of HD patients in the United States are dialyzed in ≥37 mEq/L dialysate (HCO3–) [34], while 83% of HD patients in Japan are dialyzed with dialysate (HCO3–) of <30 mEq/L [35]. Metabolic alkalosis due to the high dialysate (HCO3–) has been associated with the occurrence of cardiac arrhythmia, intradialytic hypocalcemia, hypokalemia, hypercapnia, hypoxia, intradialytic hypotension, and vascular calcification [36, 37]. In patients with chronic obstructive pulmonary disease (COPD) or other causes of ventilator impairment, higher dialysate (HCO3–) can cause CO2 accumulation and potentiate hypoxia. The DOPPS report also demonstrated a dramatic increase in mortality due to severe infection in patients receiving higher (HCO3–) dialysate [34]. Increasing dialysate (HCO3–; in the range of 28 and 40 mEq/L) induces intra-dialytic and post-dialysis alkalosis but has no effect on pre-dialysis acidosis [38, 39]. To prevent pre-dialysis acidosis, oral NaHCO3 may thus be considered.
[11/21, 7:45 PM] PG Med: The bicarb correction had also caused respiratory acidosis sir
[11/21, 7:46 PM] PG Med: His sensorium also deteriorated and when we wanted to intubate, he went into cardiac arrest
[11/21, 7:49 PM] Moderator : So what was the dialysate prescription that had been given to our patient on Day 1?
Interestingly his hypotension too was intradialytic and he had come with a normal BP on admission?
[11/21, 7:52 PM] PG Med: Yes sir presentation bp was 150/90mmhg, first intradialytic bp drop required single ionotropes for 6 hours post dialysis
[11/21, 7:52 PM] Moderator : Share his first dialysate prescription
[11/21, 7:58 PM] PG Med: Yesterday he had an episode of bradycardia in the afternoon when his pco2 wasn't raised sir,revived with atropine , so I think bradycardia is a seperate episode sir
[11/21, 8:00 PM] PG Med: Sir casesheet is dispatched
Intradialysis first day for 2hour dialysis 200 meq was given in the can sir,the rate of delivery is variable per hour, so around 75 to 50 meq was given
Second day 300meq in 4 hours , which was again 50 to 75 new/hour sir
[11/21, 8:03 PM] Moderator : How do our dialysate bicarbonate concentrations compare with the ones shared in the above linked paper
[11/21, 8:04 PM] Moderator : Did our high dialysate concentration induce metabolic alkalosis?
Also do our dialysis doctors vary the dialysate concentration in a case by case basis?
[11/21, 8:08 PM] PG Med: Vary case by case sir
[11/21, 8:08 PM] PG Med: We undercorrect it sir, only half of the requirement is given to prevent metabolic alkalosis
[11/21, 8:09 PM] PG Med: But for him as acidosis was refractory, contemplating whether we overcorrected it
[11/21, 8:11 PM] Moderator : So how do we decide how much to give?
[11/21, 8:12 PM] Moderator : His terminal acidosis was respiratory?
[11/21, 8:12 PM] PG Med: We calculate the deficit sir
And give half of it in the can and not directly if the patient can wait till dialysis,
Rate of delivery per hour ,I did not check sir
If he's having symptoms of overload we simultaneously remove more ultrafiltrate sir
[11/21, 8:12 PM] PG Med: Yes sir breaths became shallow
[11/21, 8:13 PM] Moderator : Could his respiratory depression have been due to metabolic acidosis which precipitated respiratory acidosis terminally?
[11/21, 8:15 PM] PG Med: Been trying to find that mechanism sir, the extra co2 did it come from the bicarb or did hypoventilation cause it
[11/21, 8:16 PM] Moderator : Hmm generally when we see extra Pco2 we always think respiratory while if we would have thought extra bicarb that would be reflected as metabolic alkalosis? 🤔
[11/21, 8:18 PM] PG Med: Yes sir but if his respiratory centre is compromised will alkalosis happen
[11/21, 8:18 PM] Moderator : Did he have alkalosis or acidosis?
[11/21, 8:19 PM] PG Med: Respiratory acidosis sir
[11/21, 8:19 PM] Moderator : So why think about alkalosis?
