1. pH is low , (Normal:- 7.35-7.45) HCO3 is low, (Normal:- 22-26) O2 is low, (Normal:- 80-100) Metabolic Acidosis with Hypoxemia
2.- Give Oxygen - Monitor BP, HR, RR and T , with SPO2 , aim MAP > 65mmHg, SBP > 100mmHg and SPO2 > 95% - Inform MO / Specialist if abnormal vital signs or SPO2 noted. - Upgrade Oxygen Support with or without ventilator support if SPO2 still not maintain at 95% - Give Parenteral Fluids 20cc/kg 0.9% NS , assess SBP - Give Inotropic Support until SBP >100 - CBD , with strict input/output chart to monitor the hydration status - Broad Spectrum Antibiotics - Request for CXR , USG KUB - Trace FBC, BUSE, Serum Creatine, Ca, Mg, PO4, ABG, Coag, CRP, Blood Sugar, Culture Sensitivity of Urine/ Blood - Refer to Nephrologist for Dialysis
1. Reduced pH, Decreased Oxygen levels, Raised CO2, Decreased HCO3, Base deficit of -5. Indication of Metabolic Acidosis.
2. Plan: .a.Oxygen given till 98% saturation &/ or O2 levels >90mmHg then do CXR do view pathology of right lung. b. Antibiotics to treat the infection (Augmentin 250mg BD) for 5 days. c. Repeat TLC to monitor levels. d. RFT for electrolytes level monitoring (sodium, chloride, potassium). e. Optimum hydration.
Uncompensated Metabolic acidosis because pH is low, base excess is <-2 and bicarb is low Management 1. Give oxygen, maintain spo2 98% or more 2. Treat infection , starts empirical iv antibiotic 3. Repeat abg 2hrly 4. Take sputum sample, staining, c&s 5. Cxr, renal function test,
2. Management - do cxr - find pathology of right lung -check for anion gap ( find cause of metabolic acidosis) - renal function test - monitor electrolytes level . Creatinine level , BUSE -blood sugar level , Urine for c & s Repeat abg 2hrly
1. Monitor vital sign ( hr/bp/rr/temp) 2. Give oxygen - maintain till spo2 >98% via nasal prong 3. Iv fluid to maintain hydration 4. Start with broad spectrum antibiotic for infection 5. Monitor urine output - monitor diet ( less na intake) - refer to nephro if necessary
1 ABG Uncompensated metabolic acidosis with hypoxaemia
2 Management Impression: Right sided pneumonia Further Hx: Loss of weight, loss of appetite, night sweat prev hospital admission, high risk behaviour, sick contact
INVESTIGATION Dxt Do ECG in view of tachycardia, TRO cardiac causes of arrhythmia CXR Blood: - Septic workup: blood C&S, ESR, CRP, urine C&S, RP, PO4, Mg, Ca, LFT - Sputum AFBx1, x2, x3 (if suggestive e.g. from cavitation from cxr) - Sputum MTB C&S (if suggestive e.g. cavitation from cxr) - COVID 19 PCR prior to admission
MANAGEMENT Start oxygen therapy: high flow mask Repeat ABG in 1 hour once on high flow mask, then wean down accordingly Keep SpO2 more than 95% Monitor vital signs 2 hourly, inform if Spo2 less than 95% or persistent respiratory distress, KIV to refer anaes for intubation Start broad spectrum Abx - IV Augmentin 1.2 g TDS, KIV IV Tazocin if pt has prev hospital admision To adjust antibiotics accordingly once blood C&S available Start IVD 2 pints NS/24H Strict I/O charting Allow orally if patient fully conscious Trace blood taken & CXR Correct any electrolyte abnormality Refer medical to admit SARI ward
ph : 7.33 ( acidosis) O2 : 77 (still normal at low side) co2 : 40 ( normal) HCO3 : 16 (low) BE : -5 (n : -2 to 2)
impression : uncompensated metabolic acidosis
problem list 1. Young man resp distress but metabolic acidosis. To take bedside dxt, serum ketone/urine ketone to tro dka (could be pneumonia as the precipitating factor for dka)
To take further history such as traveling hx or covid positive contact TRO covid-19. If yes, need to exclude by taking rt-pcr. Then manage patient accordingly, if dka(hydration, correct glucose, correct electrolyte imbalance, watchout for possible complications, treat precipitating factor - lung infection).
If positive covid-19, notify, contact tracing and treat accordingly.
2. lung infection evidence by symp,lung findings and leucocytosis. Sent AP erect chest x ray. sputum c+s ,AFB, blood c+s. To start with empirical antibiotics, once culture result came out, change to organism specific antibiotic.
3. For fever, to start patient with T . PCM 1g QID
4. tachypnoic .maintain spo2 >95%
Investigation to add FBC- evidence of haemolytic anaemia if mycoplasma. Renal profile (electrolite derangement) CRP/ESR LFT(atypical pneumonia effect liver) To repeat ABG To repeat FBC
HCO3 is low, (Normal:- 22-26)
O2 is low, (Normal:- 80-100)
Metabolic Acidosis with Hypoxemia
2.- Give Oxygen
- Monitor BP, HR, RR and T , with SPO2 , aim MAP > 65mmHg, SBP > 100mmHg and SPO2 > 95%
- Inform MO / Specialist if abnormal vital signs or SPO2 noted.
- Upgrade Oxygen Support with or without ventilator support if SPO2 still not maintain at 95%
- Give Parenteral Fluids 20cc/kg 0.9% NS , assess SBP
- Give Inotropic Support until SBP >100
- CBD , with strict input/output chart to monitor the hydration status
- Broad Spectrum Antibiotics
- Request for CXR , USG KUB
- Trace FBC, BUSE, Serum Creatine, Ca, Mg, PO4, ABG, Coag, CRP, Blood Sugar, Culture Sensitivity of Urine/ Blood
- Refer to Nephrologist for Dialysis
2. Plan: .a.Oxygen given till 98% saturation &/ or O2 levels >90mmHg then do CXR do view pathology of right lung. b. Antibiotics to treat the infection (Augmentin 250mg BD) for 5 days. c. Repeat TLC to monitor levels. d. RFT for electrolytes level monitoring (sodium, chloride, potassium). e. Optimum hydration.
Management
1. Give oxygen, maintain spo2 98% or more
2. Treat infection , starts empirical iv antibiotic
3. Repeat abg 2hrly
4. Take sputum sample, staining, c&s
5. Cxr, renal function test,
Interpretation: uncompesated metabolic acidosis
2. Management
- do cxr - find pathology of right lung
-check for anion gap ( find cause of metabolic acidosis)
- renal function test - monitor electrolytes level . Creatinine level , BUSE
-blood sugar level ,
Urine for c & s
Repeat abg 2hrly
1. Monitor vital sign ( hr/bp/rr/temp)
2. Give oxygen - maintain till spo2 >98% via nasal prong
3. Iv fluid to maintain hydration
4. Start with broad spectrum antibiotic for infection
5. Monitor urine output
- monitor diet ( less na intake)
- refer to nephro if necessary
Uncompensated metabolic acidosis with hypoxaemia
2 Management
Impression: Right sided pneumonia
Further Hx:
Loss of weight, loss of appetite, night sweat
prev hospital admission, high risk behaviour, sick contact
INVESTIGATION
Dxt
Do ECG in view of tachycardia, TRO cardiac causes of arrhythmia
CXR
Blood:
- Septic workup: blood C&S, ESR, CRP, urine C&S, RP, PO4, Mg, Ca, LFT
- Sputum AFBx1, x2, x3 (if suggestive e.g. from cavitation from cxr)
- Sputum MTB C&S (if suggestive e.g. cavitation from cxr)
- COVID 19 PCR prior to admission
MANAGEMENT
Start oxygen therapy: high flow mask
Repeat ABG in 1 hour once on high flow mask, then wean down accordingly
Keep SpO2 more than 95%
Monitor vital signs 2 hourly, inform if Spo2 less than 95% or persistent respiratory distress, KIV to refer anaes for intubation
Start broad spectrum Abx - IV Augmentin 1.2 g TDS, KIV IV Tazocin if pt has prev hospital admision
To adjust antibiotics accordingly once blood C&S available
Start IVD 2 pints NS/24H
Strict I/O charting
Allow orally if patient fully conscious
Trace blood taken & CXR
Correct any electrolyte abnormality
Refer medical to admit SARI ward
Uncompensated metabolic acidosis (d/t ph low, Co2 N, HCO3 low) with mild hypoxemia (paO2 <80)
ProDx: r sided Pneumonia
DDX: Tb, bronchiectasis, lung abcess (rule out by further hx and ix)
2. Plan
Ventilation:
Start NPO2 and and adjust accordingly until pt out of respi distress
Keep SPO2>95%
Oral intake:
IV drip 2 pint NS/24H
DXT QID 1/7
Monitoring:
V/S monitoring 4hourly inform if pt developed desaturation of temp spikes
Strict I/O charting
Monitor ABG level 2hrly
Medication
Start on broad spectrum Abx
IV Augmentin 1.2g TDS and T. Azithromycin 500mg OD 3/7
Change accordingly once blood cns received
Special order
Blood cns, FBC, CRP, ESR, RP
Sputum culture and AFB
Cxr
Covid swab test
ph : 7.33 ( acidosis)
O2 : 77 (still normal at low side)
co2 : 40 ( normal)
HCO3 : 16 (low)
BE : -5 (n : -2 to 2)
impression : uncompensated metabolic acidosis
problem list
1. Young man resp distress but metabolic acidosis. To take bedside dxt, serum ketone/urine ketone to tro dka (could be pneumonia as the precipitating factor for dka)
To take further history such as traveling hx or covid positive contact TRO covid-19. If yes, need to exclude by taking rt-pcr.
Then manage patient accordingly, if dka(hydration, correct glucose, correct electrolyte imbalance, watchout for possible complications, treat precipitating factor - lung infection).
If positive covid-19, notify, contact tracing and treat accordingly.
2. lung infection evidence by symp,lung findings and leucocytosis. Sent AP erect chest x ray. sputum c+s ,AFB, blood c+s. To start with empirical antibiotics, once culture result came out, change to organism specific antibiotic.
3. For fever, to start patient with T . PCM 1g QID
4. tachypnoic .maintain spo2 >95%
Investigation to add
FBC- evidence of haemolytic anaemia if mycoplasma.
Renal profile (electrolite derangement)
CRP/ESR
LFT(atypical pneumonia effect liver)
To repeat ABG
To repeat FBC
to monitor
1. symptoms improvement
2.vital signs
3. i/o chart
4.blood parameters derangement( ABG, RP,FBC)