the bicarbonate rules of thumb also known as Winters rules (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
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1 the bicarbonate rules of thumb also known as Winters rules (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
2 Outline 1 history 2 cases glycole intoxication a 27 year old diabetic 3 more formulae 4 good bye conflicts of interest (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
3 Outline 1 history 2 cases glycole intoxication a 27 year old diabetic 3 more formulae 4 good bye conflicts of interest (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
4 Outline 1 history 2 cases glycole intoxication a 27 year old diabetic 3 more formulae 4 good bye conflicts of interest (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
5 Outline 1 history 2 cases glycole intoxication a 27 year old diabetic 3 more formulae 4 good bye conflicts of interest (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
6 history background 0 The bicarbonate rules of thumb, often called Winters rules, in Australia also known as Worthley s rules, after L.I.G. Worthley, are a set of rules relating PCO 2 and bicarbonate levels to each other. They are popular as part of the bicarbonate approach to acid-base analysis popular in North America, as opposed to the base excess approach that dominates in Europe. (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
7 background 1 history Their origin can be traced to a study published in 1967 by Albert et alii. Quantitative Displacement of Acid-Base Equilibrium in Metabolic Acidosis Morris S. Albert, M.D., Ralph B. Dell, M.D., and Robert W. Winters, M.D Annals of Internal Medicine, Volume 66, No. 2, February 1967 from the Department of Pediatrics, Columbia Univeraity, College of Physicians and Surgeons, and the Babies Hospital, Columbia-Presbyterian Medical Center, New York, N. Y. (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
8 history background 2 The rules describe the normal physiological reactions of the human body to one isolated acid-base perturbance - the classical example being the hyperventilatory compensation in an otherwise healthy patient with diabetic ketoacidosis. Theoretically speaking, there is no reason why these rules ought to belong to one or another of the different schools of acid-base teaching! (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
9 history background 3 The resulting formula was slightly simplified to: PCO 2 (in mmhg) = 1.5*[HCO 3 ] (in mmol/l) + 8 ± 2 (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
10 cases glycole intoxication Outline 1 history 2 cases glycole intoxication a 27 year old diabetic 3 more formulae 4 good bye conflicts of interest (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
11 cases glycole intoxication glycole intoxication 0 measured values: ph 7.17 PCO [kpa] Na [mmol/l] K [mmol/l] Cl 108 [mmol/l] phosphate 1.3 [mmol/l] albumin 50 [g/l] calculated values: SBE -22 [meq/l] HCO 3 4 [mmol/l] (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
12 cases glycole intoxication glycole intoxication 1 an almost pure case of unknown anion metabolic acidosis glycole intoxication, 12h hours after ingestion (we did not routinely measure lactate at the time) expected PCO 2 = 1.5*[HCO 3 ] (in mmol/l) + 8 ± 2 14 mmhg or 1.84 kpa versus measured PCO kpa (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
13 cases glycole intoxication glycole intoxication 2 If you use the analysis module on acidbase.org, you get this kind of output. (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
14 cases glycole intoxication glycole intoxication 3 If you use the analysis module on acidbase.org, you get this kind of output. (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
15 cases a 27 year old diabetic Outline 1 history 2 cases glycole intoxication a 27 year old diabetic 3 more formulae 4 good bye conflicts of interest (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
16 cases a 27 year old diabetic a 27 year old diabetic 0 at admission to ICU measured values: ph 6.93 PCO [kpa] Na [mmol/l] K [mmol/l] Cl 101 [mmol/l] albumin 32 [g/l] calculated values: SBE -27 [meq/l] HCO [mmol/l] (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
17 cases a 27 year old diabetic a 27 year old diabetic 1 at admission to ICU a severe case of diabetic ketoacidosis in a young adult with known type 1 diabetes mellitus and impulsive behaviour, who in an angry fit just ignores her insulin needs expected PCO 2 = 1.5*[HCO 3 ] (in mmol/l) + 8 ± 2 12 mmhg or 1.6 kpa versus measured PCO kpa (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
18 cases a 27 year old diabetic a 27 year old diabetic 2 9 hous later measured values: ph PCO [kpa] Na [mmol/l] Cl 114 [mmol/l] calculated values: SBE -22 [meq/l] HCO [mmol/l] (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
19 cases a 27 year old diabetic a 27 year old diabetic 3 9 hous later a severe case of diabetic ketoacidosis in a young adult with known type 1 diabetes mellitus and impulsive behaviour, who in an angry fit just ignores her insulin needs expected PCO 2 = 1.5*[HCO 3 ] (in mmol/l) + 8 ± 2 18 mmhg or 2.4 kpa versus measured PCO kpa (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
20 cases a 27 year old diabetic a 27 year old diabetic 4 10 hous later (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
21 cases a 27 year old diabetic a 27 year old diabetic 4 10 hous later slow resolution of the ketoacidotic derangement no resolution of the hyperchloraemic component increasingly inadequate respiratory response 10 hours after admission to ICU severe vomiting, aspiration, respiratory and cardiac arrest severe persistent central nervous damage inspite of CPR in an ICU environment (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
22 more formulae more formulae a complete set of formulae (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
23 more formulae more formulae a complete set of formulae 1- metabolic acidosis as the primary disturbance, PCO 2 (in mmhg) in relation to [HCO 3 ] PCO 2 / HCO 3 = 1.2mmHg per meq/l 2- metabolic alkalosis as the primary disturbance, PCO2 (in mmhg) in relation to HCO 3 PCO 2 / HCO 3 = 0.7mmHg per meq/l 3- respiratory acidosis as the primary disturbance, HCO 3 in relation to PCO2 (in mmhg) 3a- acute compensation: HCO 3 / PCO 2 = 0.1mEq/l per mmhg 3b- chronic compensation: HCO 3 / PCO 2 = 0.3mEq/l per mmhg 4- respiratory alkalosis as the primary disturbance, HCO 3 in relation to PCO2 (in mmhg) 4a- acute compensation: HCO 3 / PCO 2 = 0.2mEq/l per mmhg 4b- chronic compensation: HCO 3 / PCO 2 = 0.4mEq/l per mmhg Assessing acid-base disorders Adrogué HJ, Gennari FJ, Galla JH, Madias NE Kidney Int 2009 Dec;76(12): (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
24 more formulae more formulae a complete set of formulae 1- metabolic acidosis as the primary disturbance, PCO 2 (in mmhg) in relation to [HCO 3 ] PCO 2 / HCO 3 = 1.2mmHg per meq/l 2- metabolic alkalosis as the primary disturbance, PCO2 (in mmhg) in relation to HCO 3 PCO 2 / HCO 3 = 0.7mmHg per meq/l 3- respiratory acidosis as the primary disturbance, HCO 3 in relation to PCO2 (in mmhg) 3a- acute compensation: HCO 3 / PCO 2 = 0.1mEq/l per mmhg 3b- chronic compensation: HCO 3 / PCO 2 = 0.3mEq/l per mmhg 4- respiratory alkalosis as the primary disturbance, HCO 3 in relation to PCO2 (in mmhg) 4a- acute compensation: HCO 3 / PCO 2 = 0.2mEq/l per mmhg 4b- chronic compensation: HCO 3 / PCO 2 = 0.4mEq/l per mmhg Assessing acid-base disorders Adrogué HJ, Gennari FJ, Galla JH, Madias NE Kidney Int 2009 Dec;76(12): (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
25 good bye conflicts of interest Outline 1 history 2 cases glycole intoxication a 27 year old diabetic 3 more formulae 4 good bye conflicts of interest (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
26 good bye conflicts of interest conflicts of interest
27 good bye conflicts of interest conflicts of interest my two conflicts of interest! (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
28 good bye conflicts of interest conflicts of interest my two conflicts of interest! (ICU, Herlev Hospital, Copenhagen) Winters rules Fem Minutter uge / 20
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