A 65-year-old man presents to your ED with vomiting and diarrhea over the past 5 days. He now has diminished urine output and complains of severe weakness. His medications include metformin, ramipril and atorvastatin, which he has continued to take despite volume losses. Heart rate is 110 and blood pressure 118/65. Labs show a creatinine of 320 µmol/L, sodium of 156, potassium 6.7 and serum lactate 4.1. His blood gas shows a pH of 7.02, pCO2 25, and bicarb 11. Which of the following are the most immediate life threats?