Metabolic acidosis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

A pH under 7.1 is an emergency, due to the risk of cardiac arrhythmias, and may warrant treatment with intravenous bicarbonate. Bicarbonate is given at 50-100 mmol at a time under scrupulous monitoring of the arterial blood gas readings. This intervention however, is not effective in case of lactic acidosis. If the acidosis is particularly severe and/or there may be intoxication, consultation with the nephrology team is considered useful, as dialysis may clear both the intoxication and the acidosis.

General Management

ECLS Approach to Management of Metabolic Acidosis

	ECLS Approach to Management of Metabolic Acidosis
Emergency:	intubation and ventilation for airway or ventilatory control; Cardiopulmonary resuscitation: Severe hyperkalemia
Cause:	Treat the underlying disorder as the primary therapeutic goal. Consequently, an accurate diagnosis of the cause of metabolic acidosis is very important.
Losses:	Replace losses (e.g. fluids and electrolytes) where appropriate. Other supportive care (oxygen administration) is useful. In most cases, IV sodium bicarbonate is not necessary, and may even be harmful so is not generally recommended.
Specifics:	There are often specific problems or complications associated with specific causes or specific cases that require specific management. For example, Ethanol blocking treatment with methanol ingestion; rhabdomyolysis requires management by IV fluids and uricosurics agents for preventing acute renal failure; hemodialysis can remove some nephrotoxins

Specific Treatment:

Administration of bicarbonates and dialysis is required for metabolic acidosis that is associated with Renal failure.

Restoration of adequate intravascular volume and proper peripheral perfusion is necessary for metabolic acidosis caused by lactic acidosis.

Treatment of Diabetic-ketoacidosis

• DKA is managed in an intensive care unit during the first day is always advisable
• Fluid, Insulin and electrolyte replacement are most crucial for DKA management.
• Correction of fluid loss with intravenous fluids only , Correction of hyperglycemia with insulin, Correction of electrolyte disturbances, particularly potassium loss is < 5.5, Correction of acid-base balance by bicarbonate if <7.1, Treatment of concurrent infection by antibiotics, if present.

	MANAGEMENT OF DKA AND HHS
IV fluids	Hight flow 0.9% normal saline is recommended and should be continued until corrected sodium is <135 mg/dl. Switch to .45% normal saline when Sodium >135 mg/dl. Add dextrose into 0.45% normal saline when serum glucose <200 mg/dl and sodium <135.
Insulin	Initiate continuous IV regular insulin infusion Switch to subcutaneous basal bolus insulin for the following : able to eat glucose <200 mg/dl anion gap <12 mEq/L serum bicarbonate > 15 mEq/L pH > 7.3 Overlap subcutaneous and IV insulin by 1-2 hours.
Potassium	Add IV potassium if serum potassium <5.2 mEq/L Hold insulin for serum potassium <3.3 mEq/L Nearly all patients are potassium depleted, even with hyperkalemia
Bicarbonates	Consider for patients with pH<6.9, Bicarbonate<5 and severe hyperkalemia. But mostly it is avoided as it is cause of cerebral edema in children.
phosphate	Consider for serum phosphate <1 mg/dl, cardiac dysfunction, or respiratory depression Monitor serum calcium frequently

Contraindicated medications

Metabolic acidosis is considered an absolute contraindication to the use of the following medications:

• Glyburide and Metformin
• Saxagliptin hydrochloride and Metformin hydrochloride
• Topiramate