title: Intensive care treatment of severe mixed metabolic acidosis.
abstract: We report a case of severe metabolic acidosis associated with acute renal failure and septicaemia following treatment with maximal therapeutic doses of metformin and diclofenac. On the second day of intensive care the patient deteriorated with respiratory insufficiency and abdominal pain during continuous renal replacement therapy. A laparoscopy revealed a perforated cholecystitis with abscess formation. The patient regained renal function and recovered. Intake of diclofenac 5 days before this episode could have been the main cause of renal insufficiency and metabolic acidosis in this patient and could also have delayed surgical treatment by masking early clinical signs of perforated cholecystitis. The renal failure may also have caused metformin and lactate to accumulate, contributing to the mixed pattern of metabolic acidosis. This case report describes a mixed organic and non-organic metabolic acidosis associated with acute renal failure, presumably resulting from a combination of drugs and diseases often found in the elderly - metformin for diabetes mellitus and a non-steroidal anti-inflammatory drug for cholecystolithiasis. Acid-base balance and electrolyte changes were rapidly normalized by continuous renal replacement therapy.
authors.affiliation: Deartment of Anaesthesia and Intensive Care, Lund University, Malmö University Hospital, SE-205 02 Malmö, Sweden. anders.schmidt@skane.se
authors.forename: A
authors.initials: A
authors.lastname: Schmidt
authors.forename: A
authors.initials: A
authors.lastname: Christensson
authors.forename: J
authors.initials: J
authors.lastname: Akeson
mesh_terms: D018784:Abdominal Abscess / Q000139:chemically induced / Q000601:surgery; D000138:Acidosis / Q000139:chemically induced / Q000175:diagnosis / Q000188:drug therapy*; D058186:Acute Kidney Injury / Q000139:chemically induced / Q000188:drug therapy / Q000503:physiopathology; D000368:Aged; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects / Q000627:therapeutic use; D001784:Blood Gas Analysis / Q000379:methods; D002764:Cholecystitis / Q000139:chemically induced / Q000175:diagnosis / Q000601:surgery; D003422:Critical Care / Q000379:methods*; D003924:Diabetes Mellitus, Type 2 / Q000150:complications / Q000188:drug therapy; D004008:Diclofenac / Q000009:adverse effects / Q000627:therapeutic use; D005260:Female; D006801:Humans; D007004:Hypoglycemic Agents / Q000009:adverse effects / Q000627:therapeutic use; D010535:Laparoscopy / Q000379:methods; D008687:Metformin / Q000009:adverse effects / Q000627:therapeutic use; D017582:Renal Replacement Therapy / Q000379:methods*; D018805:Sepsis / Q000139:chemically induced / Q000188:drug therapy; D012720:Severity of Illness Index
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D007004:Hypoglycemic Agents; D004008:Diclofenac; D008687:Metformin