Pavehawk Posted March 4, 2012 Share Posted March 4, 2012 I would be concerned with the lactic acidosis, metformin is not a good drug with advanced kidney disease as it can cause the aforementioned acidosis. The prognosis of metformin induced acidosis is not good. What's his BUN, creatnine and GFR, I would guess that he is in at least stage III chronic kidney failure and could actually be in acute kidney failure since he is also on lasix, which adds to my index of suspision for kindey involvment. Treat him symptomaticaly and get him to an ICU ASAP whenever the scenario allows Link to comment Share on other sites More sharing options...
island emt Posted March 4, 2012 Share Posted March 4, 2012 I agree with metformin toxicity. While it is a very commonly dispensed drug , it can have very serious side effects leading to renal failure and organ shutdown. We had a female pt that had sudden onset of loss of vision low back pain and altered mental status. She was a type 1 diabetic and had been taking metformin for many years. She had a recent UTI and was on antibiotic therapy. . The combination of meds caused her kidneys to be overloaded and decreased liver function, which caused the toxicity. She ended up coding several times over the next 3 days until they had put her on 24 hr dialysis and flushed the excess metformin from her system. Link to comment Share on other sites More sharing options...
Kiwiology Posted March 4, 2012 Author Share Posted March 4, 2012 Can we also get a cardiac panel along with a 12 Lead. The increased lactate level can be from muscle death and this pt has an extensive cardiac history 12 lead ECG AF with no ischaemic changes CK 24 CKmb 1 LDH 160 Trop-T 0.1 CRP 7 BNP 9 You're right in saying that muscle death can cause increased lactate, but what are other causes? I agree with metformin toxicity Close but no cigar as of yet Link to comment Share on other sites More sharing options...
runswithneedles Posted March 4, 2012 Share Posted March 4, 2012 Im out of ammo. Dwayne where are you?? What about metabolic acidosis. With failing kidneys and COPD. You have two of the major buffering systems compromised and any pyruvic acid created by the krebbs cycle that is not used degrades to lactic acid. Link to comment Share on other sites More sharing options...
Kiwiology Posted March 5, 2012 Author Share Posted March 5, 2012 (edited) Im out of ammo. Dwayne where are you?? He's probably off spanking the monkey because he can supply-to-administer penicillin What about metabolic acidosis. With failing kidneys and COPD. You have two of the major buffering systems compromised and any pyruvic acid created by the krebbs cycle that is not used degrades to lactic acid. Lactic acidosis is a metabolic acidosis Nobody has said he has renal failure or COPD The Kreb's cycle does not create pyruvate; the Kreb's cycle takes Acteyl CoA (made from pyruvate (glycolysis/pyruvate dehydrogenase), amino acids (from fatty acids - lipolysis) or acetate (gluconeogenesis) and creates two molecules of ATP as well as NADH + H+ and FAD(2H) In anaerobic respiration pyruvate is reduced to lactate by NADH + H+, regenerating NAD+ which is where the lactate comes from Since you gave this bloke an amp of glucose, lets say 20 minutes went by and he became hypoglycaemic again so you gave him some more glucose, does that help narrow down what might be the cause? Edited March 5, 2012 by kiwimedic Link to comment Share on other sites More sharing options...
runswithneedles Posted March 5, 2012 Share Posted March 5, 2012 Im having a brain fart WAIT!!! Is it possible he has an inefficient energy production system. Using anaerobic processes Link to comment Share on other sites More sharing options...
runswithneedles Posted March 5, 2012 Share Posted March 5, 2012 assumed he would have COPD since he is a smoker. my bad Link to comment Share on other sites More sharing options...
Kiwiology Posted March 5, 2012 Author Share Posted March 5, 2012 Is it possible he has an inefficient energy production system. Using anaerobic processes Yes it is possible, however any chronic condition such as a deficiency of a glycolytic enzyme (e.g. hexokinase) would manifest itself long ago I would think An acute problem on the other hand ... if he is becoming hypoglycaemic even with the administration of glucose what does this suggest to you? assumed he would have COPD since he is a smoker. my bad I read somewhere that half of all smoker deaths are from COPD but that only X percent of smokers will get COPD, it wasn't a huge number and that they had to be smoking something like 5 or 7 years on average, I think it was in one of my General Practice (family medicine) books And this a good lesson in not assuming Link to comment Share on other sites More sharing options...
Pavehawk Posted March 5, 2012 Share Posted March 5, 2012 If his BG continues to drop after D50 I would start to think of two things, one simple, one not so simple. First is he wearing an insulin pump? It could be malfunctioning I suppose. Another option would be an insulin secreting tumor which I can't do anything about without an OR and a better surgeon then me . His blood pressure is a high and he is acidotic he could be non compliant with his ACE (dosage please BTW) but a diabetic taking an ACE and metformin still keeps me looking at his kidney functions (the hypertension raises an eybrow too). Did anyone ask for a Chem panel, and I'm still waiting on the BUN, creatnie and GFR. Contimue treating symtomatically wait for labs BTW is he type I or type II Link to comment Share on other sites More sharing options...
Pavehawk Posted March 5, 2012 Share Posted March 5, 2012 Another thought could be alcoholic ketoacidosis not a common thing but would be part of the diff dx Link to comment Share on other sites More sharing options...
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