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QJM 2004 97(10):681-696; doi:10.1093/qjmed/hch110
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QJM vol. 97 no. 10 © Association of Physicians 2004; all rights reserved.

Masterclasses in medicine

Acidosis in a patient with cholera: a need to redefine concepts

N. Zalunardo1, M. Lemaire2, M.R. Davids3 and M.L. Halperin4

From the 1Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada, 2McGill University, Montreal, Quebec, Canada, 3Nephrology Unit and Department of Internal Medicine, Stellenbosch University, Cape Town, South Africa, and 4Division of Nephrology, St Michael's Hospital, University of Toronto, Toronto, Canada

A patient presented with cholera and a severe degree of ECF volume contraction. Despite large losses of bicarbonate ()-containing diarrhoeal fluid, laboratory acid-base values were remarkably close to normal. A detailed analysis emphasizing principles of physiology and a quantitative approach provided new insights and eventually better definitions of metabolic and respiratory acidosis. A shift in focus from concentration to content in the extracellular fluid (ECF) compartment revealed the presence of metabolic acidosis. Central to this analysis was an emphasis on the haematocrit to enable a more accurate estimate of the degree of ECF volume contraction. The latter also revealed ‘contraction’ metabolic alkalosis, which masked the underlying metabolic acidosis. The presence of a respiratory acidosis of the tissue type was evident from the raised venous PCO2, which was not surprising once the magnitude of the ECF contraction had been appreciated. ‘Bad buffering‘, as defined by Professor McCance, was the immediate danger and prompted swift action to restore an effective circulation. The haematocrit and the venous PCO2 also contribute valuable information to monitor the response to therapy. Nevertheless, there were still dangers to be discovered when an in-depth analysis suggested that the administration of isotonic saline would introduce an unanticipated danger for the patient.

Address correspondence to Professor M.L. Halperin, University of Toronto, St Michael's Hospital Annex, Lab #1, Research Wing, 38 Shuter Street, Toronto, Ontario, M5B 1A6, Canada. e-mail: mitchell.halperin{at}utoronto.ca


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