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Disturbances of Acid-Base Equilibrium1, 2,3
630
J. W. LINDSAY, E. C. RICE AND M. A. SELINGER
DISTURBANCES OF ACID-BASE EQUILIBRIUM 1, 2, 3 JANVIERW. LINDSAY, E. CLARENCE RICE AND MAURICE A. SELINGER
Dr. Hooe has presented his report partly as a text for a brief discussion of "acidosis." He has approached, from the angle of genito-urinary surgery, a subject intimately related to every phase of medical practice, whether of so-called general or special nature. This presentation seems, to those of us directly interested in laboratory work, especially appropriate, as it emphasizes one of the most important features in the care of surgical patients, namely the study of the chemistry of the body. This special type of care will have less of the character of an emergency measure, the sooner it shall be organized after it is known that surgical intervention is anticipated. It should be continued until maintenance or restoration of the chemical normal shall be assured or accomplished. A very significant feature of the report just made, is that it represents a large group of patients, many of them elective, many inevitable subjects for operation, but all of them well advanced into the period of life when they are naturally considered to be less favorable risks than those of younger age. A large percentage of these patients are classed as evidently bad risks, particularly in terms of the cardio-renal vascular system. And yet, we continually see reports of long series of patients of this group with surprisingly low mortality and remarkably rapid convalescence. We believe that general recognition of the importance of the chemical examination of the blood and urine, and the prompt application of measures to maintain the normal state in these regards has much to do with the happy result in spite of the many unfavorable factors involved. Acidosis is but a phase of the study of the acid-base equilibDiscussion of Dr. Arthur Hooe's paper. Presented at the joint meeting of the Baltimore and Washington Urological Societies Baltimore, Maryland, November 7, 1930. 3 Case reports from the Garfield Memorial and the Children's Hospitals, Washington, D. C. 1
2
DISTURBANCES OF ACID-BASE EQUILIBRIUM
631
rium of the body fluid and tissues, and is inseparably associated with the various other aspects of the problem. Only by constantly bearing in mind, this comprehensive view of any of the deviations from the normal may we avoid leaving our patient in the fog of confusion spread by the loose use of such terms as acidosis, or, as the result of over-zealous or uncontrolled efforts to relieve him, involving him in more serious diff culty than that in which we found him. An enormous amount of research work has been done upon these fluids and has revealed an amazingly fine adjustment of the balance between the acid and basic components of the blood. Even very nrinute variations from this normal balance will cause most serious if not fatal consequences. Fortunately, there are at hand and readily available relatively simple methods of examination of the blood and urine by which these all important but minute changes may be early recognized and measures taken for their correction, without requiring a repetition in detail of the procedures by which the underlying principles were demonstrated. The determination of the protein non-protein nitrogen, sugar, chlorides, calcium, carbon dioxide content and capacity of the blood, the reaction of the urine, the presence of diacetic acid, etc., have become almost routine procedures in the practice of many medical men. The use of many of these methods is not only helpful but essential in many instances in which the chemical balance is disturbed or threatened. Dr. Hooe's remarks illustrate one type and open the way to consideration of the various other types of chemical unbalance. In this instance, emphasis is placed upon "acidosis" and the features of chief interest are shown in figure 1. We look upon this patient as one who suffered from acidosis resulting from an infectious process in the bladder or respiratory tract, or both, and following a preliminary cystotomy the occurrence being favored by the naturally poor cardio-renal vascular system, which in tum was associated with marked arteriosclerosis. It was our aim to bring about correction of a number of abnormal conditions, anticipating with this accomplished, the evidence of acidosis would disappear. The anticipated result followed and
632
J. W. LINDSAY, E. C. RICE AND M. A. SELINGER
sis" did not ensue. This last observation is made in view of the fact that considerable doses of sodium bicarbonate were given, and to emphasize the importance of guarding against the transition from acidosis to "alkalosis." That the acidosis was related to the infection seems to be borne out by the very satisfactory manner in which the patient passed through the second operation; namely, prostatectomy. 789/0// X X
I)
X
47
55
THPH 34
Nn. P. 0: On. /looe Fm. 1
We would like to refer briefly to two other illustrations of acidbase distortion. The first of these is one of that large group which is now so familiar and which is generally so well studied in individual cases, namely, the acidosis associated with ketosis in diabetes. A case record has been selected because it impressed upon us certain difficulties which may arise in this group even when insulin, one of the most effective and precise therapeutic agencies we know, is available. This patient should have been a surgical case, but refused even
DISTURBANCES OF ACID-BASE EQUILIBRIUM
633
to see a surgeon, and perhaps gave us more instruction on that account, although her refusal probably nearly cost her her life. Recovered from a severe acidosis with coma at the time of the birth of her last baby, now four years of age, she suffered from most severe phlebitis 7 followed by arthritis leaving a stiff left knee joinL After about two and one-half years of gradual improvement, with quiescence of the diabetic phase of her difficulties, not-
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:~~ 2121 _
Bt.ooo SvliAII
'
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50-
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DIABETES
Frn.2
withstanding the greatest carelessness as to proper diabetic regime, there was a sudden recurrence of the infectious process clearly related to the earlier phlebitis. With the onset of coma, the patient's left leg was packed in ice. We would emphasize the fact that we do not recommend such treatment for diabetic coma. It is not the treatment of diabetic coma. Figure 2 indicates the situation with which we are especially concerned at this time, the data being taken at a recurrence of acidosis with coma after the first attack had cleared up. The
634
J. W. LINDSAY, E. C. RICE AND M. A. SELINGER
patient declined to go to the hospital, refused any intravenous therapy and could not take fluids or food by mouth. When coma superseded, we were at liberty to adopt appropriate therapy. Our special interest is in the behavior of insulin in the presence of a severe infection, particularly when associated with dehydration and the question of the use of sodium bicarbonate in severe diabetic acidosis, the latter ohe of very special importance because of the danger of the development of alkalosis. If alkalies JO
1DAYJ 5
/5
20
25
40
30
JO
~ (I)
8
(2)
~
l PnonoPLAJTY X lnANSFUS/ON.f
7
P:'CH!LDRENJ
HosP.
DI?. DONNALLY
6'------------------------~ Fw.3
be given, they must be used judiciously and carefully controlled to avoid the danger indicated. Figure 3 gives a few of the interesting features in the case of a two-month-old baby suffering from pyloric stenosis, with a history of constant vomiting and marked dehydration. There was evidence of both acidosis and later alkalosis with its typical depressed breathing and corpo-pedal spasm. The weight curve indicates the course of edema which was a marked symptom and which was associated with pyelitis. The few examinations which were possible are indicated.
DISTURBANCES OF ACID-BASE EQUILIBRIUM
635
Therapy was directed to establishment of a proper water and chemical balance an end which was eventually attained, though with intermediate marked variations indicated by the weight and chemistry curves. We have advocated the liberal use of urine and serological tests in the study of these cases, but have selected this last case to illustrate the possibility of filling in an incomplete picture by careful clinical observation and judicious therapy, where such examinations must be limited as in this instance by the age and condition of the patient concerned. The purpose of Dr. Hooe's report was to introduce the subject of "acidosis." As we have intimated, this immediately opens up the broader discussion of the maintenance and control of the acidbase equilibrium. Our knowledge of this subject has been built upon many and elaborate researches. Certain laboratory tests by which this knowledge may be correlated with the :findings in individual cases may be not only helpful, but essential. However, certain of these clinical pictures have been so frequently correlated with definite serological and urinary findings, that it is possible at times to fill in necessarily blank spaces in the latter, by carefully interpreted clinical observations. We must not treat our patients upon the basis of a loosely used chemical term, but must reckon with definite indications for definite procedures and must seek to maintain or reestablish a complete normal chemical balance from which acidosis is but one variation. This can best be accomplished by early cooperation between the surgeon, the internist and the clinical laboratory.
J. W. LINDSAY, E. C. RICE AND M. A. SELINGER
DISTURBANCES OF ACID-BASE EQUILIBRIUM 1, 2, 3 JANVIERW. LINDSAY, E. CLARENCE RICE AND MAURICE A. SELINGER
Dr. Hooe has presented his report partly as a text for a brief discussion of "acidosis." He has approached, from the angle of genito-urinary surgery, a subject intimately related to every phase of medical practice, whether of so-called general or special nature. This presentation seems, to those of us directly interested in laboratory work, especially appropriate, as it emphasizes one of the most important features in the care of surgical patients, namely the study of the chemistry of the body. This special type of care will have less of the character of an emergency measure, the sooner it shall be organized after it is known that surgical intervention is anticipated. It should be continued until maintenance or restoration of the chemical normal shall be assured or accomplished. A very significant feature of the report just made, is that it represents a large group of patients, many of them elective, many inevitable subjects for operation, but all of them well advanced into the period of life when they are naturally considered to be less favorable risks than those of younger age. A large percentage of these patients are classed as evidently bad risks, particularly in terms of the cardio-renal vascular system. And yet, we continually see reports of long series of patients of this group with surprisingly low mortality and remarkably rapid convalescence. We believe that general recognition of the importance of the chemical examination of the blood and urine, and the prompt application of measures to maintain the normal state in these regards has much to do with the happy result in spite of the many unfavorable factors involved. Acidosis is but a phase of the study of the acid-base equilibDiscussion of Dr. Arthur Hooe's paper. Presented at the joint meeting of the Baltimore and Washington Urological Societies Baltimore, Maryland, November 7, 1930. 3 Case reports from the Garfield Memorial and the Children's Hospitals, Washington, D. C. 1
2
DISTURBANCES OF ACID-BASE EQUILIBRIUM
631
rium of the body fluid and tissues, and is inseparably associated with the various other aspects of the problem. Only by constantly bearing in mind, this comprehensive view of any of the deviations from the normal may we avoid leaving our patient in the fog of confusion spread by the loose use of such terms as acidosis, or, as the result of over-zealous or uncontrolled efforts to relieve him, involving him in more serious diff culty than that in which we found him. An enormous amount of research work has been done upon these fluids and has revealed an amazingly fine adjustment of the balance between the acid and basic components of the blood. Even very nrinute variations from this normal balance will cause most serious if not fatal consequences. Fortunately, there are at hand and readily available relatively simple methods of examination of the blood and urine by which these all important but minute changes may be early recognized and measures taken for their correction, without requiring a repetition in detail of the procedures by which the underlying principles were demonstrated. The determination of the protein non-protein nitrogen, sugar, chlorides, calcium, carbon dioxide content and capacity of the blood, the reaction of the urine, the presence of diacetic acid, etc., have become almost routine procedures in the practice of many medical men. The use of many of these methods is not only helpful but essential in many instances in which the chemical balance is disturbed or threatened. Dr. Hooe's remarks illustrate one type and open the way to consideration of the various other types of chemical unbalance. In this instance, emphasis is placed upon "acidosis" and the features of chief interest are shown in figure 1. We look upon this patient as one who suffered from acidosis resulting from an infectious process in the bladder or respiratory tract, or both, and following a preliminary cystotomy the occurrence being favored by the naturally poor cardio-renal vascular system, which in tum was associated with marked arteriosclerosis. It was our aim to bring about correction of a number of abnormal conditions, anticipating with this accomplished, the evidence of acidosis would disappear. The anticipated result followed and
632
J. W. LINDSAY, E. C. RICE AND M. A. SELINGER
sis" did not ensue. This last observation is made in view of the fact that considerable doses of sodium bicarbonate were given, and to emphasize the importance of guarding against the transition from acidosis to "alkalosis." That the acidosis was related to the infection seems to be borne out by the very satisfactory manner in which the patient passed through the second operation; namely, prostatectomy. 789/0// X X
I)
X
47
55
THPH 34
Nn. P. 0: On. /looe Fm. 1
We would like to refer briefly to two other illustrations of acidbase distortion. The first of these is one of that large group which is now so familiar and which is generally so well studied in individual cases, namely, the acidosis associated with ketosis in diabetes. A case record has been selected because it impressed upon us certain difficulties which may arise in this group even when insulin, one of the most effective and precise therapeutic agencies we know, is available. This patient should have been a surgical case, but refused even
DISTURBANCES OF ACID-BASE EQUILIBRIUM
633
to see a surgeon, and perhaps gave us more instruction on that account, although her refusal probably nearly cost her her life. Recovered from a severe acidosis with coma at the time of the birth of her last baby, now four years of age, she suffered from most severe phlebitis 7 followed by arthritis leaving a stiff left knee joinL After about two and one-half years of gradual improvement, with quiescence of the diabetic phase of her difficulties, not-
234567Bomu~~u~•nmma~n~8~ '
Auwsr
li!JIJ
:~~ 2121 _
Bt.ooo SvliAII
'
1ot7!ltJ !j(J
50-
[Oz
,f()
DIABETES
Frn.2
withstanding the greatest carelessness as to proper diabetic regime, there was a sudden recurrence of the infectious process clearly related to the earlier phlebitis. With the onset of coma, the patient's left leg was packed in ice. We would emphasize the fact that we do not recommend such treatment for diabetic coma. It is not the treatment of diabetic coma. Figure 2 indicates the situation with which we are especially concerned at this time, the data being taken at a recurrence of acidosis with coma after the first attack had cleared up. The
634
J. W. LINDSAY, E. C. RICE AND M. A. SELINGER
patient declined to go to the hospital, refused any intravenous therapy and could not take fluids or food by mouth. When coma superseded, we were at liberty to adopt appropriate therapy. Our special interest is in the behavior of insulin in the presence of a severe infection, particularly when associated with dehydration and the question of the use of sodium bicarbonate in severe diabetic acidosis, the latter ohe of very special importance because of the danger of the development of alkalosis. If alkalies JO
1DAYJ 5
/5
20
25
40
30
JO
~ (I)
8
(2)
~
l PnonoPLAJTY X lnANSFUS/ON.f
7
P:'CH!LDRENJ
HosP.
DI?. DONNALLY
6'------------------------~ Fw.3
be given, they must be used judiciously and carefully controlled to avoid the danger indicated. Figure 3 gives a few of the interesting features in the case of a two-month-old baby suffering from pyloric stenosis, with a history of constant vomiting and marked dehydration. There was evidence of both acidosis and later alkalosis with its typical depressed breathing and corpo-pedal spasm. The weight curve indicates the course of edema which was a marked symptom and which was associated with pyelitis. The few examinations which were possible are indicated.
DISTURBANCES OF ACID-BASE EQUILIBRIUM
635
Therapy was directed to establishment of a proper water and chemical balance an end which was eventually attained, though with intermediate marked variations indicated by the weight and chemistry curves. We have advocated the liberal use of urine and serological tests in the study of these cases, but have selected this last case to illustrate the possibility of filling in an incomplete picture by careful clinical observation and judicious therapy, where such examinations must be limited as in this instance by the age and condition of the patient concerned. The purpose of Dr. Hooe's report was to introduce the subject of "acidosis." As we have intimated, this immediately opens up the broader discussion of the maintenance and control of the acidbase equilibrium. Our knowledge of this subject has been built upon many and elaborate researches. Certain laboratory tests by which this knowledge may be correlated with the :findings in individual cases may be not only helpful, but essential. However, certain of these clinical pictures have been so frequently correlated with definite serological and urinary findings, that it is possible at times to fill in necessarily blank spaces in the latter, by carefully interpreted clinical observations. We must not treat our patients upon the basis of a loosely used chemical term, but must reckon with definite indications for definite procedures and must seek to maintain or reestablish a complete normal chemical balance from which acidosis is but one variation. This can best be accomplished by early cooperation between the surgeon, the internist and the clinical laboratory.