Severe hypokalaemic hypochloraemic alkalosis can only
result if repeated vomiting occured while the pylorus
is closed (pyloric stenosis, pylorospasm). If vomiting
happened while the pylorus is open, the loss of
intestinal alkaline juices will neutralise chloride
acid losses from stomach resulting in normal acid-base
status. The potassium losses in hypochloraemic
alkalosis is mainly from the kidneys. This patient has
received inappropriate fluid therapy in the form of IV
dextrose (without potassium supplements) resulting in
profound hypokalaemia leading to cardiopulmonary
arrest. The appropriate fluid therapy for combating
hypochloraemic alkalosis is IV normal saline infusion
with potassium supplements. As the patient is
alcoholic, magnesium and phosphate supplemets should
also be given as well as parenteral thiamine. The
infusion should be changed to or supplemented with 10%
dextrose plus potassium supplements later on. This
patient did not receive enough chloride and that is
why his alkalosis did not improve. It can even get
worse if chloride loss is ongoing.
regards.
--- "Taylor, Andrew"
<[log in to unmask]> wrote: > I
wonder if anyone can offer an explanation of these
> results:
> patient with chronic alcohol problem, repeated
> previous admissions with
> vomiting accompanied by hypokalaemia, arrives in
> casualty:
> Sod 146
> Pot 4.0 |Bil + 42
> |GGT + 48
> Urea + 9.6 |ALP 74
> |
> Crea + 261 |Prot + 91
> |TSH 2.79
> Gluc + 7.2 |Alb 52
> |
> Calc 2.69 |ALT 30
> |
> PO4 + 2.50 |Glob + 39
> |
>
> looks dry, IV dextrose started.
> 4 hours later, patient collapses, cardiopulmonary
> resus, including further 2
> litres IV (gelofusine and Hartmann's)
>
> Sod 137 |Alb - 27
> Pot - 1.8 |Calc - 1.77
> |ALT + 66
> Bic 35 |PO4 0.81
> |Glob 29
> Urea + 8.8 |CPK + 22080
> Crea + 271 |Bil + 26
>
> Gluc 4.7 |ALP 39
> |
> |Prot - 56
> |
>
> Could the potassium fall be explained by
> rehydration? (the second potassium
> result is of course what one might expect in a
> patient with prolonged
> vomiting (K loss in gastric fluid, metabolic
> alkalosis due to H loss in
> gastric fluid causing potassium shift into cells,
> loss in urine)). Note the
> fall in albumin is suggestive of significant
> expansion of plasma volume
> having occurred, but the urea isn't.
> incidentally the CK is attributed to neuroleptic
> drug
>
>
=====
Dr. M A Al-Jubouri
Consultant Chemical Pathologist
Whiston Hospital
Prescot
Merseyside L35 5DR
UK
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