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Revision as of 17:22, 26 July 2013
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Metabolic acidosis Microchapters |
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Diagnosis |
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Treatment |
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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
Common Causes
Low Anion Gap
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
| History, symptoms and physical examination Blood pH < 7.35 | |||||||||||||||||||||||||||||||||||||||||
| Physical Examination Eyes, extremities Neurologic (cranial nerves) | Labs/EKG Anion gap, Arterial blood gas analysis Electrolytes (Na, K, Cl, HCO3) CBC Serum lactate, ketone Urinalysis Toxicological screening (salicylate, methanol, ethylene glycol) EKG for arrhythmias | History Arrhythmias Kussmaul breathing Headache, altered mental status | |||||||||||||||||||||||||||||||||||||||
| Place patient on EKG monitor for arrhythmias, hyperkalemia | Replace electrolytes if there are losses | If DKA, IV Insulin, normal saline Potassium and Phosphate may be necessary | Send consult to Nephrologist for dialysis for renal failure, poisoning | Toxicological consult | |||||||||||||||||||||||||||||||||||||
| IV Bicarbonate if there is cardiac arrhythmias 50-100mmol while monitoring arterial blood gas readings | Detoxification agents/Toxin antidotes Fomepizole Activated charcoal Emesis Folic acid for methanol overdose Thiamine and pyridoxine for ethylene glycol overdose | ||||||||||||||||||||||||||||||||||||||||
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