FEN and Acid Base Disorders

RH is a 27yo male (68kg, 71”) with a past medical history significant for type 1 diabetes. He presents to the ED with a two-day history of “not feeling right,” which he says is similar to the last time he was in the hospital. He reports that his blood sugar is usually well controlled, however his pump has been acting up recently. His blood sugar comes back elevated at 632, BHBT at 3.9mM, WBC 12.7, SCr 1, Na 127, K 4.8, CL 103, CO₂ 12, pH 7.1. All other labs are unremarkable.

1) The medical resident approaches you and asks if he should give “an amp of bicarb” to correct RH’s acidosis. What is the most correct response?

You are starting your shift when you hear two of your physicians discussing a patient that has recently arrived. He is confused and unable to provide any identification or history, though he appears to be approximately 50yo. His VBG/BMP results show pH 7, pCO₂ 40, CO₂ 15, glucose 127, SCr 1.3, Na 134, Cl 99, and K 4.2, the rest of his VBG and BMP were unremarkable, and no other labs have resulted yet.

2) The physicians turn to you and ask if any medications could have caused this metabolic acidosis.  Which of the following is the best response?

SK is a 72yo female (77kg, 64”) with a past medical history of type 2 diabetes, hypertension, hyperlipidemia, stage 2 chronic kidney disease, and atrial fibrillation for which she takes metformin, glipizide, lisinopril, atorvastatin, metoprolol, and warfarin. Her temperature is 100.7°F, RR 17, HR 79, O₂ saturation 96%, WBC 14.3, SCr 1.2, lactate 4.6, glucose 157, Na 142, Cl 108, K 4.8, CO₂ 22, and pH 7.3. All other labs are within normal limits.

3) Your facility currently requires 30 mL/kg of IV fluid to be administered to this patient as she meets criteria for your sepsis activation protocol, however it does not differentiate between normal saline and lactated ringers. Which of the following is the most appropriate recommendation to make regarding fluid selection?

MS is a 38yo female (97kg, 65”) who presents to your ED for evaluation of abdominal pain. She reports no past medical history, and only takes a calcium + vitamin D supplement regularly. She does report taking “a lot” of Tums and ibuprofen recently to help her stomach aches. She has also been making her own “alkaline water” with baking soda. All her vital signs are normal, and her BMP shows glucose 92, SCr 2, Na 4, Cl 102, K 4.1, CO₂ 34, Ca 14. Her VBG shows a pH of 7.5.

4) The provider thinks that MS may be presenting with Milk Alkali Syndrome and asks for recommendations. Which is the most appropriate treatment recommendation for MS in addition to holding her current home medications?

PL is a 72yo male (74kg, 68”) who presents to the ED with a foot infection and concern for osteomyelitis. Past medical history is significant for hypertension, hyperlipidemia, and diabetes for which he takes lisinopril, atenolol, simvastatin, and insulin glargine. His vital signs and initial labs are as follows: temperature 101°F, RR 20, HR 92, O₂ saturation 98%, WBC 13.1, SCr 1.6 (baseline 1), lactate 4.2, all electrolytes are within normal limits.

5) The physician expresses concern for a diabetic foot infection and wants to initiate the patient on vancomycin and piperacillin/tazobactam to broadly cover for likely pathogens in this patient, however he is concerned about that combination of antibiotics as the patient appears to have an acute kidney injury and he heard that piperacillin/tazobactam becomes nephrotoxic when combined with vancomycin. Which of the following is the most appropriate response?

KP is a 63yo female (56kg, 60”) brought into the ED as a stroke alert with concern for altered mental status. As she is alone and from out of state, you are unable to obtain any of her past medical history. After a neurologic assessment rules out acute ischemic stroke, the team begins to look for other causes of her altered mental status. Her vital signs are all within normal limits, and her BMP results are as follows: BUN 82 mg/dL, CO₂ 25 mg/dL, SCr 2.5, glucose 142, Cl 96, K 4.8, Na 132, Ca 9 mg/dL. Toxicology screen is negative.

6) The physician is concerned that KP may require emergent dialysis. Which of the following lab results most supports that concern?

GW is a 27yo male (87kg, 70”) with past medical history significant for anxiety and chronic alcohol use disorder. He has been prescribed an SSRI in the past but is not currently taking any medication. He endorses drinking a case of beer daily with minimal food as “the beer fills [him] up,” but expresses interest in detox and a psychiatric admission.

7) Which of the following electrolyte derangements would you expect to see in GW?

GW is a 27yo male (87kg, 70”) with past medical history significant for anxiety and chronic alcohol use disorder. He has been prescribed an SSRI in the past but is not currently taking any medication. He endorses drinking a case of beer daily with minimal food as “the beer fills [him] up,” but expresses interest in detox and a psychiatric admission.

8) GW’s sodium resulted at 120mEq/L, he is not showing any symptoms of hyponatremia. Which of the following would be the most appropriate correction strategy?

HC is a 63yo male (98kg, 67”) with a history of stage 3 chronic kidney disease, hypertension, and cellulitis on his leg for which he was recently started on trimethoprim/sulfamethoxazole. He also takes lisinopril and reports taking ibuprofen regularly for headaches. His labs and vital signs are as follows: temperature 99.1°F, RR 17, HR 71, O₂ saturation 98%, SCr 2.1 (baseline 1.4), glucose 92, Cl 101, K 5.8, Na 142. His EKG shows moderately peaked T waves.

9) Which of the following treatment regimens lists the ordered medications in the most appropriate administration order for HC?

TK is a 27yo female (42kg, 63”) who arrives in the ED in active cardiac arrest with ACLS protocol being followed. You are unable to obtain any of her medication information. A point of care BMP shows SCr 0.6, glucose 74, Cl 97, K <2.4, Na 134.

10) After assessing her Hs and Ts for reversible causes of cardiac arrest, the team suspects that hypokalemia is the most likely cause. Which is the best initial strategy replace her potassium?