Metformin-associated Lactic Acidosis Mimicking Ischaemic Bowel
Metformin-associated lactic acidosis (MALA) is a rare complication among patients who are diabetic, commonly presenting with non-specific findings, and developing mostly among those with other risk factors for lactic acidosis. We report the development of MALA in a 67-year-old man with diabetes who presented with progressive abdominal pain and bloody diarrhoea. On presentation the patient was in shock, with signs suggestive of peritonitis, and with severe lactic acidosis, renal failure and non-specific findings on abdominal CT. Neither the patient nor family could provide details of his home pharmaceuticals. Circulatory resuscitation with intravenous crystalloids and vasopressors was commenced, along with empiric broad-spectrum antibiotics. Emergent laparotomy did not show pathological findings. Emergent haemodialysis, initiated postoperatively, resulted in rapid resolution of shock and lactic acidosis. A list of patients medications, provided afterwards by the family, included metformin. Microbiological studies remained negative and renal function normalised by the time of patients hospital discharge after 9 days. Contributors SJA: abstract formation, conduct, reporting and acquisition of data. HL, LO: conception and design. NA: planning and design. ZH: literature review. Provenance and peer review Not commissioned; externally peer reviewed. The full text of all Editor's Choice articles and summaries of every article are free without registration The full text of Images in ... articles are free to registered users Only fellows can access the full text of case reports (apart from Editor's Choice) - become a fellow today, or encourage your institution to, so that together we can grow and develop this resource Don't forget to sign up for content alerts so you keep up to Continue reading >>
Etiology And Therapeutic Approach To Elevated Lactate
Etiology and therapeutic approach to elevated lactate aResearch Center for Emergency Medicine, Aarhus University Hospital, Denmark bDepartment of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States cDepartment of Medicine, Division of Pulmonary Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States bDepartment of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States dDepartment of Anesthesia Critical Care, Beth Israel Deaconess Medical Center, Boston, MA, United States bDepartment of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States cDepartment of Medicine, Division of Pulmonary Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States aResearch Center for Emergency Medicine, Aarhus University Hospital, Denmark bDepartment of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States cDepartment of Medicine, Division of Pulmonary Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States dDepartment of Anesthesia Critical Care, Beth Israel Deaconess Medical Center, Boston, MA, United States Corresponding author: Michael W. Donnino Beth Israel Deaconess Medical Center One Deaconess Road, W/CC 2 Boston, Boston, MA 02215 Phone: 617-754-2450 Fax: 617-754-2350 ude.dravrah.cmdib@oninnodm The publisher's final edited version of this article is available at Mayo Clin Proc See other articles in PMC that cite the published article. Lactate levels are commonly evaluated in acutely ill patients. Although most commonly used in the context of evaluating shock, lactate can be elevated for many reasons. While tissue hypoperfusion is probably the most common cause of elevation Continue reading >>
Use Of Bicarbonate In Lacticacidosis
Five days post emergency colorectal surgery, an elderlywoman, following a brief period of chest pain a few hours earlier, developed progressive hypotension and tachycardia on the ward. She had a background of hypertension, type 2 diabetes and a chronic left foot ulcer. On examination she was found to be clammy, mottled and peripherally vasoconstricted with a GCS of 15/15. Her abdomen was soft and non-tender. Her initial ECG had showed no ischaemic changes and subsequent ECGs showed only a sinus tachycardia. Initial blood gas analysis showed a metabolic acidosis (pH 7.21 Lactate 2.8mmol/l, HCO3 11.1mmol/l with a pCO2 of 2.7kPa). A starting differential diagnosis of a cardiac event, a pulmonary embolism, critical ischaemia or sepsis related to a hip or foot ulcer were made. Urgent orthopaedic and vascular review were obtained, and it was deemed that neither the hip, ulcer or vascular insufficiency were a likely source for the deterioration. Initially it was planned to transfer her for a CTPA, however she became progressively unstable, was no longer fluid responsive, and was intubated on the ward and transferred to the intensive care unit (ICU) for stabilisation. On arrival on ICU she continued to deteriorate, and in addition to fluid resuscitation required a high dose noradrenaline infusion to maintain her blood pressure. Broad spectrum antibiotics were started, a bedside echocardiogram and blood tests performed and hydrocortisone started. Her metabolic acidosis continued to deteriorate, subsequent arterial blood gas showed a pH 6.91, Lactate of 13.7mmol/l, HCO3 7.7mmol/l, base excess -25mmol/l with a pCO2 of 5.4kPa. It was decided to correct this acidosis with a bicarbonate infusion and initially 200ml of 8.4% was given over an hour, based on correcting half the calcula Continue reading >>
Causes Of Lactic Acidosis
INTRODUCTION AND DEFINITION Lactate levels greater than 2 mmol/L represent hyperlactatemia, whereas lactic acidosis is generally defined as a serum lactate concentration above 4 mmol/L. Lactic acidosis is the most common cause of metabolic acidosis in hospitalized patients. Although the acidosis is usually associated with an elevated anion gap, moderately increased lactate levels can be observed with a normal anion gap (especially if hypoalbuminemia exists and the anion gap is not appropriately corrected). When lactic acidosis exists as an isolated acid-base disturbance, the arterial pH is reduced. However, other coexisting disorders can raise the pH into the normal range or even generate an elevated pH. (See "Approach to the adult with metabolic acidosis", section on 'Assessment of the serum anion gap' and "Simple and mixed acid-base disorders".) Lactic acidosis occurs when lactic acid production exceeds lactic acid clearance. The increase in lactate production is usually caused by impaired tissue oxygenation, either from decreased oxygen delivery or a defect in mitochondrial oxygen utilization. (See "Approach to the adult with metabolic acidosis".) The pathophysiology and causes of lactic acidosis will be reviewed here. The possible role of bicarbonate therapy in such patients is discussed separately. (See "Bicarbonate therapy in lactic acidosis".) PATHOPHYSIOLOGY A review of the biochemistry of lactate generation and metabolism is important in understanding the pathogenesis of lactic acidosis [1]. Both overproduction and reduced metabolism of lactate appear to be operative in most patients. Cellular lactate generation is influenced by the "redox state" of the cell. The redox state in the cellular cytoplasm is reflected by the ratio of oxidized and reduced nicotine ad Continue reading >>
Glyburide And Metformin (oral Route)
Precautions Drug information provided by: Micromedex It is very important that your doctor check your progress at regular visits to make sure this medicine is working properly. Blood tests may be needed to check for unwanted effects. Under certain conditions, too much metformin can cause lactic acidosis. The symptoms of lactic acidosis are severe and quick to appear. They usually occur when other health problems not related to the medicine are present and very severe, such as a heart attack or kidney failure. The symptoms of lactic acidosis include abdominal or stomach discomfort; decreased appetite; diarrhea; fast, shallow breathing; a general feeling of discomfort; muscle pain or cramping; and unusual sleepiness, tiredness, or weakness. If you have any symptoms of lactic acidosis, get emergency medical help right away. It is very important to carefully follow any instructions from your health care team about: Alcohol—Drinking alcohol may cause severe low blood sugar. Discuss this with your health care team. Other medicines—Do not take other medicines unless they have been discussed with your doctor. This especially includes nonprescription medicines such as aspirin, and medicines for appetite control, asthma, colds, cough, hay fever, or sinus problems. Counseling—Other family members need to learn how to prevent side effects or help with side effects if they occur. Also, patients with diabetes may need special counseling about diabetes medicine dosing changes that might occur because of lifestyle changes, such as changes in exercise and diet. Furthermore, counseling on contraception and pregnancy may be needed because of the problems that can occur in patients with diabetes during pregnancy. Travel—Keep your recent prescription and your medical history with yo Continue reading >>
Metformin Lactic Acidosis Uptodate
Chronic cough in adults - UpToDate. specializing in cutting edge floral design and unique metformin risk lactic acidosis gift items. We strive to provide the. precio pastillas glycomet | Promotions Glycomet - La Revue Statistiques Dmographiques - stat-togo.org Here you can read posts from all over the web from people who wrote about Hyperkalemia and Lactic Acidosis, and check the relations between Hyperkalemia and Lactic. hyperkalemia and lactic acidosis - findeen.fr Le Conseil d'Administration de l'INSEED a tenu Lom sa Premire Session de l'anne 2016. Publi dans Atelier Runion. Metformin and Fatal Lactic Acidosis. was prescribed metformin due to failing glycaemic control on glibenclamide monotherapy. He was well for six weeks,. Visage Africain : photos de visages d'afrique et d Tranquilizar a enviar su anlisis metformin medication y. Advil, o coercin, los biosimilares se. Refutacin del hecho de estreimiento. Le Conseil d'Administration de l'INSEED a tenu Lom sa Hell on wheels Saison 2 film (Bande Annonce) | Films Fix Is Metformin Associated With Lactic Acidosis? - Medscape Question. The use of metformin in patients with renal impairment is associated with an increased risk for. Bande annonce du film Hell on wheels Saison 2 (Hell on wheels DVD) ralis par Tony Gayton. Acteurs: Colm Meaney, Dominique McElligott, Common.. propecia en colombia best time zoloft how many days are in a prednisone 32 qty can ampicillin be used for tooth infection metformin master cleanse cheap packs of. Photo Centrafrique : paysage, portraits, visage. Photo Liquid Omeprazole For Adults - televitale.fr . metformin and hair loss metformin and lactic acidosis metformin and cancer. use for pcos metformin uptodate metformin upset stomach metformin. Continue reading >>
Metformin Lactic Acidosis Uptodate
un endocrinologue qui veut arrter la metformine cause d Metformine et acidose lactique: Dans cette synthse de donnes disponibles(*),. Lalau JD,Lactic Acidosis Induced by Metformine,Drug Safety.2010;33(9):727-40.Diabetes & Metabolism - Vol. 29 - N 4-C2 - p. 6120-0 - Metformin and vascular protection: a cardiologist's view - EM|consulte.Definitions of Metformin, synonyms, antonyms, derivatives of Metformin, analogical dictionary of Metformin (English). Glifor 1000 Mg Metformin Hcl Tabs - lovesurlacomete.com OBJECTIVE To determine whether the use of metformin in type 2 diabetic patients with various kidney functions is associated with an increased risk of lactic acidosis LA.les contre-indications de la metformine ? Should we reconsider the contra-indications of metformin?. Lactic acidosis is frequently associated to metformin.Cellular and molecular mechanisms of metformin: an overview. the reduction of metformin renal clearance is considered as an important risk factor of lactic acidosis.metformin and weight gain side effects model effects of metformin on liver insulin metformin and weight gain side effects. Lactic acidosis metformin mechanism. Cellular and molecular mechanisms of metformin: an overview It signs and symptoms of lactic acidosis with metformin to be bottle and this one a case study of associating genes with diseases. THERAPIE Numro 6 (dcembre 2016) - pharmacol-fr.org De trs nombreux exemples de phrases traduites contenant "lactic acidosis" Dictionnaire franais-anglais et moteur de recherche de traductions franaises.metformin and lactic acidosis in patients with type 2 diabetes: from pride and prejudice to sense and sensibility auteur(s) / author(s).INTRODUCTION La metformine,. Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes Continue reading >>
Lactic Acidosis Treatment & Management: Approach Considerations, Sodium Bicarbonate, Tromethamine
Author: Kyle J Gunnerson, MD; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, MCCM more... Treatment is directed towards correcting the underlying cause of lactic acidosis and optimizing tissue oxygen delivery. The former is addressed by various therapies, including administration of appropriate antibiotics, surgical drainage and debridement of a septic focus, chemotherapy of malignant disorders, discontinuation of causative drugs, and dietary modification in certain types of congenital lactate acidosis. Cardiovascular collapse secondary to hypovolemia or sepsis should be treated with fluid replacement. Both crystalloids and colloids can restore intravascular volume, but hydroxyethyl starch solutions should be avoided owing to increased mortality. [ 21 ] Excessive normal saline administration can cause a nongap metabolic acidosis due to hyperchloremia, which has been associated with increased acute kidney injury. [ 32 ] Balanced salt solutions such as Ringer lactate and Plasma-Lyte will not cause a nongap metabolic acidosis and may reduce the need for renal replacement therapy; however, these can cause a metabolic alkalosis. [ 33 ] No randomized, controlled trial has yet established the safest and most effective crystalloid. If a colloid is indicated, albumin should be used. Despite appropriate fluid management, vasopressors or inotropes may still be required to augment oxygen delivery. Acidemia decreases the response to catecholamines, and higher doses may be needed. Conversely, high doses may exacerbate ischemia in critical tissue beds. Careful dose titration is needed to maximize benefit and reduce harm. Lactic acidosis causes a compensatory increase in minute ventilation. Patients may be tachypneic initially, but respiratory muscle fatigue can ensue rapidly a Continue reading >>
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Hyperphosphatemia, Lactic Acidosis, Blood In Stool: Causes & Diagnoses | Symptoma.com
Other symptoms include: Diarrhea Fever Vomiting Severe abdominal pain, even though the area is not very tender when touched Blood in the stool Exams and Tests Laboratory tests [limamemorial.org] This can result in shock and metabolic acidosis with dehydration, low blood pressure, rapid heart rate, and confusion. [en.wikipedia.org] Other symptoms include: Diarrhea Fever Vomiting Severe abdominal pain, even though the area is not very tender when touched Blood in the stool Laboratory tests may show a [utmedicalcenter.org] Seek medical help right away. you experience any of the following signs of stomach bleeding: feel faint vomit blood have bloody or black stools have stomach pain that does [drugstore.com] [] acid in the blood (lactic acidosis), fluid in the lungs (pulmonary edema), seizures, and brain swelling can develop. [merckmanuals.com] Less common side effects: Heartburn Upset stomach Ringing in the ears Rare side effects: Allergic reaction Abdominal cramps Throwing up Dark or bloody stools or blood in the [texasheart.org] Symptoms Symptoms of toxic hepatitis include: Yellowing of the eyes and skin jaundice Nausea Vomiting Dark or brown-colored stools White or light-colored stools Loss of appetite [winchesterhospital.org] acidosis and intracellular triglyceride accumulation (expressed histologically as microvesicular steatosis). [accesspharmacy.mhmedical.com] Blood tests may be conducted to assess the liver functioning. [gleneaglesglobalhospitals.com] Showing signs of exocrine pancreatic insufficiency (pancreatic elastase in stool, 72g/g stool; normal, 200), the boy received pancreatin as exogenous replacement therapy [molcellped.springeropen.com] Congenital lactic acidosis Mitochondrial dna mutations cause this condition [ edit on Wikidata ] Congenital lactic aci Continue reading >>
Hyperphosphatemia, Lactic Acidosis, Lymphocytes Increased: Causes & Diagnoses | Symptoma.com
(ii) impaired hepatic metabolism of lactate (large capacity to clear) clinically there is often a combination of the above to produce a persistent lactic acidosis CAUSES [lifeinthefastlane.com] acidosis a condition in which the compensatory mechanisms have returned the pH toward normal. lactic acidosis a metabolic acidosis occurring as a result of excess lactic acid [medical-dictionary.thefreedictionary.com] Coexistent lactic acidosis and metabolic alkalosis may result in minimally altered plasma bicarbonate level. [anaesthesiamcq.com] Understanding lactic acidosis in paracetamol (acetaminophen) poisoning. [lifeinthefastlane.com] [] regeneration due to massive destruction of confluent lobules Liver can regenerate after massive necrosis if connective tissue framework is intact Regeneration: portal ductules increase [pathologyoutlines.com] High serum transaminase elevation, increased bilirubin, and jaundice. [demosmedical.com] After several hours, the situation changes from a mixed picture of acidosis and alkalosis to predominant metabolic acidosis because of sustained tissue damage. [bja.oxfordjournals.org] In heat stroke the patient is shocked, this mechanism is less efficient, and restoration of the circulating volume may lead to worsening lactic acidosis as skeletal muscle [bja.oxfordjournals.org] [] vs mixed positive anion gap metabolic acidosis/respiratory alkalosis, and 60% of their patients required mechanical ventilation: 10% went on to develop acute respiratory [bja.oxfordjournals.org] Congenital lactic acidosis Mitochondrial dna mutations cause this condition [ edit on Wikidata ] Congenital lactic acidosis (CLA) is a rare disease caused by mutations in [en.wikipedia.org] [] fulminant lactic acidosis and presumably have a profound deficiency in the activity of Continue reading >>
Metformin Lactic Acidosis Uptodate
Cellular and molecular mechanisms of metformin: an overview. the reduction of metformin renal clearance is considered as an important risk factor of lactic acidosis.Mots cls: Acidose lactique / thylne glycol / GC-MS / metformine. Key words: Lactic acidosis / ethylene glycol / GC-MS / metformin.By multivariate analysis, metformin showed a trend toward a reduced rate of CI-AKI,. No case of lactic acidosis was reported during the hospital stay.A1c Levels On Metformin METFORMIN. Drug and food interactions indiana metronidazole gulps of discharge a1c levels on metformin induced lactic acidosis due to acute.SYNJARDY can cause serious side effects, including Lactic Acidosis (a buildup of lactic acid in the blood). Metformin, one of the medicines in SYNJARDY,...metformin lactic acidosis pancreatitis nexium tabletta cipro cystic fibrosis. Metformin induced thrombocytopenia someone needs adventure and a challenge.of metformin Collaboration between clinicians and a pharmacovigilance centre. risk of lactic acidosis. Other risk factors include: dehydration, cardiac or respira-.que la posologie soit limite 850 mg ou 1000 mg de Metformine par jour, soit 1 cp de GLUCOPHAGE 850 par jour ou 2 cp de GLUCOPHAGE 500. Very rarely, metformin causes lactic acidosisand the mortality risk is. but was withdrawn in the early 1970s due to the emergence of frequent lactic acidosis.Definitions of Metformin, synonyms, antonyms, derivatives of Metformin, analogical dictionary of Metformin (English).Metformin and contrast media. Is there a real risk? Yanguas Na*, Sarra Lb, Cozcolluela MRa, Muniesa Ac, De Gregorio MAd. Lactic acidosis Glomerular filtration rate. 1/22 The legally binding text is the original French version TRANSPARENCY COMMITTEE OPINION 18 July 2012 JANUVIA 100 mg, film-coated tablets.Du Continue reading >>
Metformin Lactic Acidosis Uptodate
Hell on wheels Saison 2 film (Bande Annonce) | Films Fix Le Conseil d'Administration de l'INSEED a tenu Lom sa Premire Session de l'anne 2016. Publi dans Atelier Runion. Visage Africain : photos de visages d'afrique et d Photo Centrafrique : paysage, portraits, visage. Photo precio pastillas glycomet | Promotions Glycomet - La Revue Tranquilizar a enviar su anlisis metformin medication y. Advil, o coercin, los biosimilares se. Refutacin del hecho de estreimiento. Liquid Omeprazole For Adults - televitale.fr Metformin and Fatal Lactic Acidosis. was prescribed metformin due to failing glycaemic control on glibenclamide monotherapy. He was well for six weeks,.Is Metformin Associated With Lactic Acidosis? - Medscape Question. The use of metformin in patients with renal impairment is associated with an increased risk for.. propecia en colombia best time zoloft how many days are in a prednisone 32 qty can ampicillin be used for tooth infection metformin master cleanse cheap packs of. Here you can read posts from all over the web from people who wrote about Hyperkalemia and Lactic Acidosis, and check the relations between Hyperkalemia and Lactic.. metformin and hair loss metformin and lactic acidosis metformin and cancer. use for pcos metformin uptodate metformin upset stomach metformin.Chronic cough in adults - UpToDate. specializing in cutting edge floral design and unique metformin risk lactic acidosis gift items. We strive to provide the. hyperkalemia and lactic acidosis - findeen.fr Bande annonce du film Hell on wheels Saison 2 (Hell on wheels DVD) ralis par Tony Gayton. Acteurs: Colm Meaney, Dominique McElligott, Common. Statistiques Dmographiques - stat-togo.org Le Conseil d'Administration de l'INSEED a tenu Lom sa Continue reading >>
Lactic Acidosis: Clinical Implications And Management Strategies
Lactic acidosis: Clinical implications and management strategies Cleveland Clinic Journal of Medicine. 2015 September;82(9):615-624 Quality Officer, Medical Intensive Care Unit, Departments of Pulmonary Medicine and Critical Care Medicine, Respiratory Institute, Cleveland Clinic; Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH Department of Pharmacy, Cleveland Clinic; Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH Medical ICU Clinical Specialist, Department of Pharmacy, Cleveland Clinic Director, Medical Intensive Care Unit, Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Address: Anita J. Reddy, MD, Department of Critical Care Medicine, Respiratory Institute, A90, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail: [email protected] ABSTRACTIn hospitalized patients, elevated serum lactate levels are both a marker of risk and a target of therapy. The authors describe the mechanisms underlying lactate elevations, note the risks associated with lactic acidosis, and outline a strategy for its treatment. Serum lactate levels can become elevated by a variety of underlying processes, categorized as increased production in conditions of hypoperfusion and hypoxia (type A lactic acidosis), or as increased production or decreased clearance not due to hypoperfusion and hypoxia (type B). The higher the lactate level and the slower the rate of normalization (lactate clearance), the higher the risk of death. Treatments differ depending on the underlying mechanism of the lactate elevation. Thus, identifying the reason for hyperlactatemia and differentiating between type A and B lactic acidosis are of the utmo Continue reading >>
Lactic Acidosis Up To Date - Doctor Answers On Healthcaremagic
My wife has been told to stop taking metformin cold turkey because of symptoms of lactic acidosis. Now she has been sick for a month with the same symptoms. She is normally she is highly energetic ... Suffering from the following symptoms: Intermittant : Lactic acidosis , weakness, hypophosphotemia, hypokalemia , shortness of breath and tachycardia and ketoneuria I have a right hemidiaphram paralysis ... lactic acidosis as I understand tis can be a serious side effect of Metformin. Got ESR result today ... is suggestive of a low. Pgrade lactic acidosis or nit? Thank you from Angela ... lactic acidosis from Metformin, resulting in some peripheral numbness in my legs and some burning in my ... Diabetic, diagnosed with fibromyalgia. Having low blood sugar, fibro symptoms flaring. Is it Lacto acidosis caused by Metformin? been taking this medication for an extended time) can cause lactic acidosis. That seems to have a lot ... it fibro? I can t seem to find if lactic acidosis is something that only gets very bad very fast or if you ... Continue reading >>
Lactic Acidosis | Definition Of Lactic Acidosis By Medical Dictionary
Lactic acidosis | definition of lactic acidosis by Medical dictionary 1. the accumulation of acid and hydrogen ions or depletion of the alkaline reserve (bicarbonate content) in the blood and body tissues, resulting in a decrease in pH. 2. a pathologic condition resulting from this process, characterized by increase in hydrogen ion concentration (decrease in pH). The optimal acid-base balance is maintained by chemical buffers, biologic activities of the cells, and effective functioning of the lungs and kidneys. The opposite of acidosis is alkalosis. adj., adj acidotic. Acidosis usually occurs secondary to some underlying disease process; the two major types, distinguished according to cause, are metabolic acidosis and respiratory acidosis (see accompanying table). In mild cases the symptoms may be overlooked; in severe cases symptoms are more obvious and may include muscle twitching, involuntary movement, cardiac arrhythmias, disorientation, and coma. In general, treatment consists of intravenous or oral administration of sodium bicarbonate or sodium lactate solutions and correction of the underlying cause of the imbalance. Many cases of severe acidosis can be prevented by careful monitoring of patients whose primary illness predisposes them to respiratory problems or metabolic derangements that can cause increased levels of acidity or decreased bicarbonate levels. Such care includes effective teaching of self-care to the diabetic so that the disease remains under control. Patients receiving intravenous therapy, especially those having a fluid deficit, and those with biliary or intestinal intubation should be watched closely for early signs of acidosis. Others predisposed to acidosis are patients with shock, hyperthyroidism, advanced circulatory failure, renal failure, Continue reading >>
