Case report
Nondiabetic ketoacidosis in a pregnant woman due to acute starvation with concomitant influenza A (H1N1) and respiratory failure
Cetoacidosis no diabética en una mujer embarazada, debido a inanición aguda con gripe A (H1N1) concomitante e insuficiencia respiratoria
Critical Care Department, King's College Hospital, London, United Kingdom
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"apellidos" => "Antolín" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935618300100" "doi" => "10.1016/j.redar.2018.01.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935618300100?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918300970?idApp=UINPBA00004N" "url" => "/23411929/0000006500000007/v1_201807260406/S2341192918300970/v1_201807260406/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Nondiabetic ketoacidosis in a pregnant woman due to acute starvation with concomitant influenza A (H1N1) and respiratory failure" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "407" "paginaFinal" => "412" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "G. Skalley, S. Rodríguez-Villar" "autores" => array:2 [ 0 => array:2 [ "nombre" => "G." "apellidos" => "Skalley" ] 1 => array:4 [ "nombre" => "S." "apellidos" => "Rodríguez-Villar" "email" => array:1 [ 0 => "sancho.rodvil@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Critical Care Department, King's College Hospital, London, United Kingdom" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cetoacidosis no diabética en una mujer embarazada, debido a inanición aguda con gripe A (H1N1) concomitante e insuficiencia respiratoria" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 844 "Ancho" => 950 "Tamanyo" => 55673 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Plain chest radiography in the intensive care unit revealed a bilateral patchy consolidation. This is predominantly in the lingula and possibly left lower lobe. Further consolidation is seen in the perihilar region on the right side with a more distal wedge area of opacification in the right upper lobe. There appears to be some volume loss in the right upper lobe. There are no pleural effusions. Appearances would be in keeping with an infective process.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">This report presents a case of life-threatening refractory nondiabetic ketoacidosis due to acute starvation in a pregnant woman. Starvation-induced ketoacidosis is in itself a rare entity, but is even more unusual in pregnancy; only 11 similar cases have been reported in the literature.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">1–8</span></a> Metabolic acidosis has severe consequences for the patient and the foetus,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a> and pregnancy itself predisposes to ketoacidosis<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">9</span></a>in a shorter period of time compared to non-pregnant patients.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">10,11</span></a> This case report adds to the expanding body of literature on this condition, and describes the management strategy and importance of early recognition.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 35-year-old woman presented to the emergency department (ED) at 34 weeks of gestation with a 1-week history of shortness of breath and productive cough with clear sputum. In the 3 days prior to ED admission she had also experienced fever and rigour. Over the previous 10 days she reported reduced oral intake, eating just 1 or 2 biscuits and other snacks per day over this period.</p><p id="par0015" class="elsevierStylePara elsevierViewall">At presentation, she was alert but pale, and presented tachycardia (heart rate of 130 beats per minute), tachypnoea (respiratory rate of 32 breaths per minute), and blood pressure of 108/66. She had difficulty speaking due to shortness of breath, kussmaul's breathing, with oxygen saturation of 92% on room air. Body temperature was 37.8<span class="elsevierStyleHsp" style=""></span>°C. The physical examination found bilateral crepitations on auscultation of the lungs, worse on the left, with expiratory wheezing. She also reported epigastric pain when coughing. The rest of the examination was unremarkable.</p><p id="par0020" class="elsevierStylePara elsevierViewall">An arterial blood gas analysis performed with the patient receiving 2<span class="elsevierStyleHsp" style=""></span>L/min oxygen via a nasal cannula showed mixed metabolic acidosis with respiratory alkalosis, and type 1 respiratory failure (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, Day 0). Urinalysis revealed ketones ++++ and protein +. Chest X-ray (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) showed predominantly left-sided lower lobe pneumonia with bilateral consolidation. Based on these findings, community acquired pneumonia was diagnosed. The patient was admitted for treatment and started on amoxicillin and clarithromycin, and given 500<span class="elsevierStyleHsp" style=""></span>mL of 1.26% bicarbonate for compensated metabolic acidosis.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">After 17<span class="elsevierStyleHsp" style=""></span>h under the care of the medical team, her condition deteriorated. Oxygen delivery was increased to 15<span class="elsevierStyleHsp" style=""></span>L/min via an oxygen mask in order to maintain oxygen saturation of 95%.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was transferred to the intensive care unit (ICU) and steroid therapy was started to promote foetal lung maturity should an emergency caesarean section be needed. Cardiotocography (CTG) was performed regularly by the obstetric team, showing foetal tachycardia caused by the maternal stress response. The patient remained dyspnoeic, with clammy skin and generally poor clinical status. Oseltamivir was started due to the clinical suspicion of viral influenza. This was later confirmed by rRT-PCR assay (Trioplex rRT-PCR), with low white cell count (WCC) low despite high C-reactive protein (CPR) (WCC: 10.1, CRP: 201). The patient was switched to high flow nasal cannula (HFNC) oxygen therapy at 45<span class="elsevierStyleHsp" style=""></span>L/min with 65% oxygen.</p><p id="par0035" class="elsevierStylePara elsevierViewall">After 24<span class="elsevierStyleHsp" style=""></span>h in the ICU we were able to reduce HFNC to 45% oxygen, maintaining the same flow rate of 45<span class="elsevierStyleHsp" style=""></span>L/min for an oxygen saturation of 98%. The patient's acidosis however worsened (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, day 1). Base excess increased from −4.8 to −13.2, with a rapid decrease in bicarbonate levels and increased anion gap (AG).<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">A follow-up blood gas analysis showed a complex acid-base disorder, with an albumin-corrected anion gap of 56.67 (9.17<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>47.5), and a delta ratio of 30.67 (56.67<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span>(12/24)<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span>10). This confirmed the initial suspicion of a complex acid-base disorder: high anion gap metabolic acidosis with concomitant respiratory alkalosis and possible metabolic acidosis. We diagnosed starvation ketoacidosis and a stress response. Serum ketones at this point measured 4.1<span class="elsevierStyleHsp" style=""></span>mg/dL (normal range: 0.5–3.0<span class="elsevierStyleHsp" style=""></span>mg/dL), and urinary ketones +++.</p><p id="par0045" class="elsevierStylePara elsevierViewall">We assumed that the respiratory compensation for the worsening metabolic acidosis may have exacerbated her work of breathing, considering that she already had extensive bilateral lung consolidation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Infusion of 1.26% sodium bicarbonate was started, administering a total of 700<span class="elsevierStyleHsp" style=""></span>mL over 4<span class="elsevierStyleHsp" style=""></span>h, and the patient was scheduled for emergency caesarean section. However, the life-threatening refractory metabolic acidosis worsened despite bicarbonate infusion, and dextrose infusion was started 1<span class="elsevierStyleHsp" style=""></span>h prior to the start of the caesarean section, based on her history of starvation and ketonaemia. She was intubated and ventilated with bilevel positive airway pressure, with positive end expiratory pressure (PEEP) set at 10 and pressure support set at 22 above PEEP, and FiO<span class="elsevierStyleInf">2</span> of 35% oxygen.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The patient returned from theatre sedated, intubated and ventilated. The dextrose infusion had continued during the intervention. She remained intubated for 14<span class="elsevierStyleHsp" style=""></span>h post-surgery and dextrose infusion was maintained for a total of 24<span class="elsevierStyleHsp" style=""></span>h at a rate of 100<span class="elsevierStyleHsp" style=""></span>mL/h. The patient's base excess returned to normal levels within 7<span class="elsevierStyleHsp" style=""></span>h of surgery.</p><p id="par0055" class="elsevierStylePara elsevierViewall">At 8<span class="elsevierStyleHsp" style=""></span>h post-surgery, the patient started to receive nutrition via her nasogastric (NG) tube, initially at 20<span class="elsevierStyleHsp" style=""></span>mL/h, and within 4<span class="elsevierStyleHsp" style=""></span>h her urine was negative for ketones. She remained in the ICU for a further 24<span class="elsevierStyleHsp" style=""></span>h, during which time her NG nutrition was increased to 60<span class="elsevierStyleHsp" style=""></span>mL/h, and she started oral intake of solids and liquids. She was subsequently discharged to the maternity ward.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">We present a case of non-diabetic ketoacidosis in a pregnant woman with influenza and respiratory failure due to acute starvation. Although this type of acidosis is a rare pathophysiological phenomenon, the pathophysiological mechanism is well known. It unfortunately has severe consequences for the pregnant patient and her foetus, as she initially did not respond to standard treatment, and starvation ketoacidosis is easily overlooked due to its rarity.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In this case, we initially focussed on the more obvious diseases, which were pneumonia and the high anion gap metabolic disorder. In our differential diagnosis, we considered the possible common causes of the patient's metabolic disorder, and followed a systematic analytical approach using an algorithm for complex acid base disorders (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). We knew that this patient had a complex acid–base disorder with low pCO<span class="elsevierStyleInf">2</span>, low HCO<span class="elsevierStyleInf">3</span>, high base excess and acidic pH. The AG was high, but unfortunately serum osmolality was not performed, so we worked through the different causes of AG metabolic acidosis in both high and low serum osmolal gap (SOG).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">High SOG would allow us to rule out excessive alcohol consumption, as the patient denied a history of alcohol consumption, smoking or illicit drug use, and there was nothing in her history to suggest ingestion of ethylene, methanol, diethylene, and propylene. High AG with low SOG would allow us to rule out all the causes listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. The patient's lactate was normal throughout her hospital stay (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), making the diagnosis of lactic acidosis unlikely. We assessed her paracetamol and salicylate levels, which were 7<span class="elsevierStyleHsp" style=""></span>mg/L and undetectable, respectively.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The ultimate diagnosis of ketoacidosis was difficult, as the patient was otherwise healthy, with no history of alcohol or illicit drug use. Previous glucose tolerance testing did not show any abnormalities, and the patient was not diabetic. Renal function was normal. There were no precipitating factors other than the short period of starvation. We made the diagnosis of starvation ketoacidosis because the metabolic acidosis was associated with high levels of both urinary and serum ketones (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), resistant to treatment with sodium bicarbonate, and very rapidly resolved with the administration of 5% dextrose.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Ketoacidosis usually occurs in the context of uncontrolled diabetes mellitus.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a> Insulin deficiency prevents cellular uptake of glucose for energy, leading to counterregulatory hormone release. The combination of low insulin levels and circulating hormones releases free fatty acids, which are oxidised in the liver to form ketone bodies.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">9</span></a> Similar metabolic changes can occur in starvation.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Starvation ketoacidosis is a type of metabolic acidosis that occurs in prolonged fasting. The lack of dietary calorie intake reduces the amount of glucose entering the body. This depletes glycogen stores, and alternative energy is generated from free fatty acids and from the production of ketone bodies.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">6,7</span></a> Ketoacidosis occurs when the production of ketone bodies exceeds the body's energy requirements,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a> and this leads to metabolic acidosis. In healthy individuals, it takes at least 14 days for starvation to reach the height of its severity, and blood pH is commonly above 7.3 with mildly elevated ketones.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">4,12</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The risk of ketoacidosis however, is increased in pregnancy and all hypermetabolic states,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> in which there is a relative state of accelerated starvation, particularly in the second and third trimester. The foetus and the placenta consume large amounts of maternal glucose for energy, leading to decreased maternal fasting glucose.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> Ketogenesis is also increased in pregnancy, as normal gestation is a diabetogenic state,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> creating a state of insulin resistance.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> These factors lead to enhanced lipolysis and increased free fatty acids in the pregnant patient, increasing the overall production of ketone bodies.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> In a period of fasting as short as 12<span class="elsevierStyleHsp" style=""></span>h (overnight), levels of ketone bodies can be 2–4 times higher than in non-pregnant women.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">10,11</span></a> Furthermore, the pregnant patient is at increased risk of metabolic acidosis.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a> Due to increased minute volume ventilation,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> pregnancy causes respiratory alkalosis.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> This is metabolically compensated by increased renal excretion of bicarbonate,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> so plasma bicarbonate concentration falls during the third trimester, reducing its buffering capacity <a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a>when exposed to an acid such as ketone bodies.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">This case involved a pregnant patient with type 1 respiratory failure who, after a period of acute starvation, was kept nil by mouth whilst in hospital, leading to severe metabolic acidosis. Early recognition and management of starvation ketoacidosis is essential for the wellbeing of the patient, and reduces the risk of impaired neurodevelopment in the foetus.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a> Treatment should focus on removing the causative agent, namely, production of ketone bodies and gluconeogenesis, and this is achieved by administering intravenous (IV) insulin and dextrose<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a>; although it has also been successfully managed with dextrose alone.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a> Cases of starvation ketoacidosis in pregnancy have been reported in the literature, and nearly always <a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a>requires emergency caesarean section and IV dextrose.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In hindsight, our patient could have been treated earlier, and thus could have avoided an emergency caesarean section. Ketones were detected in her urine during clerking (she was known to be non-diabetic), subsequent arterial blood gas tests showed metabolic acidosis, and she reported a history of reduced oral food intake to the first clinician to examine her. This and similar case reports<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a> highlight the importance of a systematic diagnostic approach to acid base disorders. Our approach, which ultimately led us to the correct diagnosis, is presented in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. This case is clinically important because it occurred in a patient with respiratory failure and sepsis; however, the diagnostic methodology was the same as in earlier cases, and will hopefully raise awareness of the importance of timely diagnosis and management of starvation ketoacidosis in pregnancy.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical statement</span><p id="par0105" class="elsevierStylePara elsevierViewall">Written informed consent was obtained directly from the patient for publication of this case report. Ethical approval was not necessary because the report focuses on the retrospective observation of the patient's treatment, and therefore did not affect her therapy in any way.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Location of study</span><p id="par0110" class="elsevierStylePara elsevierViewall">The study was performed at Princess Royal University Hospital (King's College NHS Trust Foundation).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Author contributions</span><p id="par0115" class="elsevierStylePara elsevierViewall">S.R.V and G.S. were the main study researchers. S.R.V and G. S. drafted the manuscript.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflict of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors certify that they have no affiliations with or involvement in any organisation or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this report.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1065114" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1013124" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1065115" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1013123" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Ethical statement" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Location of study" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Author contributions" ] 10 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-09-22" "fechaAceptado" => "2018-01-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1013124" "palabras" => array:4 [ 0 => "Nondiabetic ketoacidosis" 1 => "Pregnancy" 2 => "Starvation" 3 => "Influenza A" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1013123" "palabras" => array:4 [ 0 => "Cetoacidosis no diabética" 1 => "Embarazo" 2 => "Inanición" 3 => "Gripe A" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Threatening refractory metabolic acidosis due to short-term starvation nondiabetic ketoacidosis is rarely reported. Severe ketoacidosis due to starvation itself is a rare occurrence, and more so in pregnancy with a concomitant stressful clinical situation.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This case report presents a nondiabetic woman admitted in intensive care for respiratory failure type 1 during the third trimester of pregnancy with a severe metabolic acidosis refractory to medical treatment.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We diagnosed the patient with acute starvation ketoacidosis based on her history and the absence of other causes of high anion gap metabolic acidosis after doing a rigorous analysis of her acid-base disorder.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Raramente se reporta la acidosis metabólica resistente de riesgo debido a cetoacidosis no diabética por inanición a corto plazo. La cetoacidosis grave debida a inanición es una situación infrecuente y lo es más aún durante el embarazo con situación clínica estresante concomitante.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Este informe de un caso presenta a una mujer no diabética ingresada en cuidados intensivos debido a insuficiencia respiratoria tipo 1 durante el tercer trimestre de embarazo, con acidosis metabólica grave resistente a tratamiento médico.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Diagnosticamos a la paciente de cetoacidosis por inanición, basándonos en su historia y la ausencia de otras causas de acidosis metabólica con anión gap elevado, tras la realización de un análisis riguroso de su trastorno ácido-base.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Skalley G, Rodríguez-Villar S. Cetoacidosis no diabética en una mujer embarazada, debido a inanición aguda con gripe A (H1N1) concomitante e insuficiencia respiratoria. Rev Esp Anestesiol Reanim. 2018;65:407–412.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 844 "Ancho" => 950 "Tamanyo" => 55673 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Plain chest radiography in the intensive care unit revealed a bilateral patchy consolidation. This is predominantly in the lingula and possibly left lower lobe. Further consolidation is seen in the perihilar region on the right side with a more distal wedge area of opacification in the right upper lobe. There appears to be some volume loss in the right upper lobe. There are no pleural effusions. Appearances would be in keeping with an infective process.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">PEEP, positive end expiratory pressure. IPPV, intermittent positive-pressure ventilation. BIPAP, Bilevel positive airway pressure.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Day & hour \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Day 0 ED 11:00<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Day 1 obstetric dependency 8:00<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Day 1 ICU 11:00<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Day 1 ICU 18:00<span class="elsevierStyleHsp" style=""></span>h 1<span class="elsevierStyleHsp" style=""></span>h post caesarean section \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Day 1 ICU 21:00<span class="elsevierStyleHsp" style=""></span>h 4<span class="elsevierStyleHsp" style=""></span>h post theatre \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Day 2 ICU 6:00<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Day 2 ICU 18:00<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Day 3 ICU 7:00<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oxygen support \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2<span class="elsevierStyleHsp" style=""></span>L 100% O<span class="elsevierStyleInf">2</span> via nasal cannula \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">High flow oxygen 45% at 45<span class="elsevierStyleHsp" style=""></span>L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">High flow oxygen 45% at 45<span class="elsevierStyleHsp" style=""></span>L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intubated IPPV pressure support 24, PEEP 10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intubated BIPAP pressure support 22, PEEP 10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intubated BIPAP pressure support 22, PEEP 10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">High flow oxygen 30% at 35<span class="elsevierStyleHsp" style=""></span>L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">High flow oxygen 30% at 35<span class="elsevierStyleHsp" style=""></span>L \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sodium Bicarbonate infusion 1.26% mmol/L and mEq/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">500<span class="elsevierStyleHsp" style=""></span>mL over 5<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">700<span class="elsevierStyleHsp" style=""></span>mL over 4<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100<span class="elsevierStyleHsp" style=""></span>mL/h (total 4<span class="elsevierStyleHsp" style=""></span>h pre-surgery) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5% dextrose infusion for a total of 24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100<span class="elsevierStyleHsp" style=""></span>mL/h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100<span class="elsevierStyleHsp" style=""></span>mL/h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100<span class="elsevierStyleHsp" style=""></span>mL/h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100<span class="elsevierStyleHsp" style=""></span>mL/h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100<span class="elsevierStyleHsp" style=""></span>mL/h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">pH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.53 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PCO<span class="elsevierStyleInf">2</span> kPa and mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.97 and 22.27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.64 and 19.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.27 and 17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.88 and 36.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.11 and 30.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.96 and 37.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.30 and 32.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.62 and 34.65 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PO<span class="elsevierStyleInf">2</span> kPa and mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.72 and 87.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.66 and 87.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.89 and 81.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22.47 and 168.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14.01 and 105 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13.47 and 101 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.44 and 78.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.80 and 73.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HCO<span class="elsevierStyleInf">3</span> mmol/L and mEq/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SBE mmol/L and mEq/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−9.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−11.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−13.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−13.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−8.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Art Sat % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">94.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">97.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lactate mmol/L and mEq/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.98 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Serum Ketones mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Negative \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urinary Ketones \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+++++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+++++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">++++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">++++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Negative \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Glucose mmol/L and mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.7 and 120 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.8 and 140 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 and 145 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.1 and 110 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1816189.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">ICU observation chart.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">AG<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span> gap; SOG<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>serum osmolal gap. SOG<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>serum osmolality (measured)<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span>serum osmolarity (calculated in the laboratory).</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">• SOG<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>measured serum osmolality<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>[Na<span class="elsevierStyleSup">+</span><span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>K<span class="elsevierStyleSup">+</span>]<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>urea nitrogen (mg/dL)/2, 8<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>glucose (mg/dL)/18.</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">• SOG<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>measured serum osmolality<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>[Na<span class="elsevierStyleSup">+</span><span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>K<span class="elsevierStyleSup">+</span>]<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>urea (mmol/L)<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>glucose (mmol/L).</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Remember</span>: the presence of osmolal gap depends on several factors, such as baseline SOG, molecular weight of alcohol and time after exposure.</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Reproduced with permission from ‘The ABG algorithm: simple approach to analysis of acid–base disorders’<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a> Courtesy of S. Rodríguez-Villar.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">SOG<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>mOsm/kg \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">SOG<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>mOsm/kg \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Ethylene glycol<br>•<span class="elsevierStyleHsp" style=""></span>Alcohol (ethanol)<br>•<span class="elsevierStyleHsp" style=""></span>Methanol<br>•<span class="elsevierStyleHsp" style=""></span>Diethylene glycol<br>•<span class="elsevierStyleHsp" style=""></span>Propylene glycol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Lactic acidosis, lactate > 2 mEq/L(2<span class="elsevierStyleHsp" style=""></span>mmol/L)<br>–<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Type A.</span> Hypoxia, hypotension, hypovolemia and sepsis<br>–<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Type B.</span> (no evidence of tissue hypoxia):<br>♦<span class="elsevierStyleHsp" style=""></span>Diabetic ketoacidosis, hyperosmolar hyperosmotic non-ketonic coma<br>♦<span class="elsevierStyleHsp" style=""></span>Liver disease (reduced lactate clearance)<br>♦<span class="elsevierStyleHsp" style=""></span>Thiamine deficiency<br>♦<span class="elsevierStyleHsp" style=""></span>Cyanide poisoning<br>♦<span class="elsevierStyleHsp" style=""></span>Widespread malignancy<br>♦<span class="elsevierStyleHsp" style=""></span>Short bowel syndrome<br>♦<span class="elsevierStyleHsp" style=""></span>Pheohromocytoma<br>♦<span class="elsevierStyleHsp" style=""></span>Alcohol consumption<br>♦<span class="elsevierStyleHsp" style=""></span>Drugs such as paracetamol, epinephrine, salbutamol, terbutalina, linezolid, metformin, propofol, nitroprusiate, nucleoside reverse transcriptase inhibitors and propylene glycol (a solvent present in some intravenous medications including lorazepam, diazepam), esmolol, nitroglycerin, phenytoin and iron overdose<br>♦<span class="elsevierStyleHsp" style=""></span>Blood samples are stored for a prolonged period, cells continually metabolise glucose to lactate and may falsely elevate the lactate content of the sample.<br>♦<span class="elsevierStyleHsp" style=""></span>Other clinical conditions (seizures and acute asthma, respiratory muscles exhaustion).<br>–<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Type D</span>. Lactic acidosis due to conversion of carbohydrate into organic acids (slow GI transit or change of normal flora)<br>•<span class="elsevierStyleHsp" style=""></span>Acute or chronic renal failure<br>•<span class="elsevierStyleHsp" style=""></span>Other drugs: salicylates & paraldehyde<br>•<span class="elsevierStyleHsp" style=""></span>Acute starvation \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1816190.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Differential diagnosis of high anion gap metabolic acidosis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0095" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Normoglycemic diabetic ketoacidosis in pregnancy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Chico" 1 => "S.N. Levine" 2 => "D.F. Lewis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/sj.jp.7211921" "Revista" => array:6 [ "tituloSerie" => "J Perinatol" "fecha" => "2008" "volumen" => "28" "paginaInicial" => "310" "paginaFinal" => "312" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18379571" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0100" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute starvation in pregnancy: a cause of severe metabolic acidosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Patel" 1 => "D. Felstead" 2 => "M. Doraiswami" 3 => "G.M. Stocks" 4 => "U. 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