Metabolic acidosis resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ogheneochuko Ajari, MB.BS, MS [2]

Definition

Metabolic acidosis is a state in which the blood pH is low (less than 7.35) due to increased production of H⁺ by the body or the inability of the body to form bicarbonate (HCO₃^-) in the kidney.

Causes

Life Threatening Causes

• Diabetic ketoacidosis
• Ethylene Glycol poisoning
• Lactic acidosis
• Methanol

Common Causes

Low Anion Gap

• Hypoalbuminemia
• Multiple myeloma

Normal Anion Gap Metabolic Acidosis

The mnemonic for the most common causes of a normal-anion gap metabolic acidosis is "DURHAM."

• D- Diarrhea
• U- Ureteral diversion
• R- Renal tubular acidosis
• H- Hyperalimentation
• A- Addison's disease, acetazolamide, ammonium chloride
• M- Miscellaneous (congenital chloride diarrhea, amphotericin B, toluene - toluene causes high anion gap metabolic acidosis followed by normal anion gap metabolic acidosis

Increased/High Anion Gap Metabolic Acidosis

The mnemonic "MUDPILES" is used to remember the common causes of a high anion gap.

• M - Methanol/Metformin
  
• U - Uremia
  
• D - Diabetic ketoacidosis
  
• P - Paraldehyde/Propylene glycol
  
• I - Infection/Ischemia/Isoniazid
  
• L - Lactate
  
• E - Ethylene glycol/Ethanol
  
• S - Salicylates/Starvation

Management

Shown below is the algorithm summarizing the management of metabolic acidosis

B01

C01

C02

C03

D01

D02

D03

D04

D05

E01

E02

Do's

• Treatment of the underlying cause should be the primary therapeutic goal.
• Bicarbonate should be given only when there is a severe case of acidosis with an arterial pH of less than or equal to 7.0
• Patient should be placed on SaO2 and blood pressure/heart rate monitor
• Consider intubation and ventilation for airway if the SaO2 level is deteriorating or there is a loss of consciousness
• Consider doing catherization to monitor the urine output and obtaining urine for urinalysis

Dont's

• Do not give vasoconstrictors in the presence of lactic acidosis