Andrievskaya M, Peisach D, and Yee J. Non-conventional therapy of a triple acid base disorder. Am J Kidney Dis 2018; 71(4):521.
Am J Kidney Dis
Severe electrolyte derangements are difficult to correct and standard approaches are not always successful. We present a case in which an unconventional treatment approach led to resolution of a severe, mixed acid-base disorder. A 74-year-old female with a history of stroke, seizures, and chronic hyponatremia presented with confusion, gait difficulty, and poor oral intake. Initial vital signs T 36.3 °C, BP 97/52 mm Hg, HR 70 bpm, RR 16 min-1, BMI 19 kg/m2. Admission lab data revealed Na 118, K 3.2, Cl 89, TCO2 23 mmol/L, BUN 11, SCr 0.76, Mg 1.5, Pi 1.7 mg/dL. ABG pH 7.76, pCO2 12.5 mm Hg. Diagnoses of ketolactic acidosis from starvation with metabolic and respiratory alkaloses were established by elevations of serum lactate (3.9 mmol/L) and beta hydroxybutyrate (1.07 mmol/L) levels. To prevent aggravation of hyponatremia by free-water glucose infusions yet treat the ketosis, a concentrated sugar solution comprised of addition of 20 grams of glucose to 20 oz (contains 77 grams of total carbohydrates) of phosphorus-free Mountain Dew was administered. Cerebral perfusion compromise from hyperventilation and life threateningly high pH were offset by intubation with addition of dead space via increased tubing length. Hypokalemia and hypophosphatemia, from dietary deprivation, were addressed with potassium phosphate administered at 0.5 mmol/kg/day. Hyponatremia, attributed to SIADH with superimposed volume depletion, was gradually corrected at 6-8 mmol/L/day. Within 24 hours, ketone production was suppressed and arterial pH lowered to 7.41 with pCO2 of 31.8 mm Hg. This case demonstrates efficacy of a sugar-sweetened beverage to treat starvation ketosis, and mechanical hypoventilation to correct severe respiratory alkalosis. In addition to utilizing traditional protocols, physicians must be creative and consider non-conventional approaches to patients.