Metabolic Acidosis in Emergency Medicine Treatment & Management

  • Author: Antonia Quinn, DO; Chief Editor: Erik D Schraga, MD   more...
 
Updated: Nov 13, 2009
 

Emergency Department Care

The initial therapeutic goal for patients with severe acidemia is to raise the systemic pH above 7.1-7.2, a level at which dysrhythmias become less likely and cardiac contractility and responsiveness to catecholamines will be restored.

Metabolic acidosis can be reversed by treating the underlying condition or by replacing the bicarbonate. The decision to give bicarbonate should be based upon the pathophysiology of the specific acidosis, the clinical state of the patient, and the degree of acidosis.

Treating the underlying conditions in high AG states usually is sufficient in reversing the acidosis. Treatment with bicarbonate is unnecessary, except in extreme cases of acidosis when the pH is less than 7.1-7.2. For all cases of diabetic ketoacidosis, the role of bicarbonate is controversial, regardless of the pH or bicarbonate level.

In hyperchloremic acidosis, the central problem is with the reabsorption or regeneration of bicarbonate. In these conditions, therapy with bicarbonate makes physiologic sense and is prudent in patients with severe acidosis.

Caution with bicarbonate therapy is indicated because of its potential complications, including the following:

  • Volume overload
  • Hypokalemia
  • CNS acidosis
  • Hypercapnia
  • Tissue hypoxia via leftward shift of hemoglobin-oxygen dissociation curve
  • Alkali stimulation of organic acidosis (lactate)
  • Overshoot alkalosis
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Consultations

Metabolic acidosis secondary to ingestions (eg, salicylate, methanol, ethylene glycol) often requires dialysis therapy, and a nephrologist should be consulted early in the case management. Toxicologic consultation should also be considered in such cases. Dialysis is the preferred treatment for patients with significant metabolic acidosis in the setting of renal failure.

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Contributor Information and Disclosures
Author

Antonia Quinn, DO  Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate Medical Center/Kings County Hospital Center; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Antonia Quinn, DO is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO  Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Erik D Schraga, MD  Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Howard A Bessen, MD  Professor of Medicine, Department of Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Program Director, Harbor-UCLA Medical Center

Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD  Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Karen L Stavile, MD, to the development and writing of this article.

References

  1. Reddy P, Mooradian AD. Clinical utility of anion gap in deciphering acid-base disorders. Int J Clin Pract. Oct 2009;63(10):1516-25. [Medline].

  2. Stewart PA. Modern quantitative acid-base chemistry. Can J Physiol Pharmacol. Dec 1983;61(12):1444-61. [Medline].

  3. Gokhale YA, Vaidya MS, Mehta AD, Rathod NN. Isoniazid toxicity presenting as status epilepticus and severe metabolic acidosis. J Assoc Physicians India. Jan 2009;57:70-1. [Medline].

  4. Dell'aglio DM, Perino LJ, Kazzi Z, Abramson J, Schwartz MD, Morgan BW. Acute Metformin Overdose: Examining Serum pH, Lactate Level, and Metformin Concentrations in Survivors Versus Nonsurvivors: A Systematic Review of the Literature. Ann Emerg Med. Jun 24 2009;[Medline].

  5. Adrogue HJ, Madias NE. Management of life-threatening acid-base disorders. Second of two parts. N Engl J Med. Jan 8 1998;338(2):107-11. [Medline].

  6. Adrogue HJ, Madias NE. PCO2 and [K+] in metabolic acidosis: certainty for the first and uncertainty for the other. J Am Soc Nephrol. Jun 2004;15(6):1667-8. [Medline].

  7. Adrogué HJ, Madias NE. Changes in plasma potassium concentration during acute acid-base disturbances. Am J Med. Sep 1981;71(3):456-67. [Medline].

  8. Arbus GS. An in vivo acid-base nomogram for clinical use. Can Med Assoc J. Aug 18 1973;109(4):291-3. [Medline].

  9. Charles JC, Heilman RL. Clinical Review Article: Metabolic Acidosis. Hosp Physician. 2005;41:37-42.

  10. Dempsey GA, Lyall HJ, Corke CF, et al. Pyroglutamic acidemia: a cause of high anion gap metabolic acidosis. Crit Care Med. Jun 2000;28(6):1803-7. [Medline].

  11. Emmett M, Narins RG. Clinical use of the anion gap. Medicine (Baltimore). Jan 1977;56(1):38-54. [Medline].

  12. Englehart MS, Schreiber MA. Measurement of acid-base resuscitation endpoints: lactate, base deficit, bicarbonate or what?. Curr Opin Crit Care. Dec 2006;12(6):569-74. [Medline].

  13. Fulop M. A guide for predicting arterial CO2 tension in metabolic acidosis. Am J Nephrol. 1997;17(5):421-4. [Medline].

  14. Fulop M. Serum potassium in lactic acidosis and ketoacidosis. N Engl J Med. May 10 1979;300(19):1087-9. [Medline].

  15. Garibotto G, Sofia A, Robaudo C, et al. Kidney protein dynamics and ammoniagenesis in humans with chronic metabolic acidosis. J Am Soc Nephrol. Jun 2004;15(6):1606-15. [Medline].

  16. Kellum JA. Disorders of acid-base balance. Crit Care Med. Nov 2007;35(11):2630-6. [Medline].

  17. Kellum JA. Metabolic acidosis in the critically ill: lessons from physical chemistry. Kidney Int Suppl. May 1998;66:S81-6. [Medline].

  18. Kurtzman NA. Renal tubular acidosis: a constellation of syndromes. Hosp Pract (Off Ed). Nov 15 1987;22(11):173-8, 181, 184 passim. [Medline].

  19. Kwong SC, Brubacher J. Phenformin and lactic acidosis: a case report and review. J Emerg Med. Nov-Dec 1998;16(6):881-6. [Medline].

  20. Lloyd P. Strong ion calculator--a practical bedside application of modern quantitative acid-base physiology. Crit Care Resusc. Dec 2004;6(4):285-94. [Medline].

  21. McSherry E. Renal tubular acidosis in childhood. Kidney Int. Dec 1981;20(6):799-809. [Medline].

  22. Mitchell JH, Wildenthal K, Johnson RL Jr. The effects of acid-base disturbances on cardiovascular and pulmonary function. Kidney Int. May 1972;1(5):375-89. [Medline].

  23. Mohler JG, Mohler PA, Pallivathucal RG. Failure of the serum CO2 determined by automation to estimate the plasma bicarbonate. Scand J Clin Lab Invest Suppl. 1987;188:61-7. [Medline].

  24. Müller-Plathe O. A nomogram for the interpretation of acid-base data. J Clin Chem Clin Biochem. Nov 1987;25(11):795-8. [Medline].

  25. Narins RG, Emmett M. Simple and mixed acid-base disorders: a practical approach. Medicine (Baltimore). May 1980;59(3):161-87. [Medline].

  26. Nguyen HB, Rivers EP, Knoblich BP, et al. Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med. Aug 2004;32(8):1637-42. [Medline].

  27. O'Dell E, Tibby SM, Durward A, et al. Hyperchloremia is the dominant cause of metabolic acidosis in the postresuscitation phase of pediatric meningococcal sepsis. Crit Care Med. Oct 2007;35(10):2390-4. [Medline].

  28. Richardson RM, Halperin ML. The urine pH: a potentially misleading diagnostic test in patients with hyperchloremic metabolic acidosis. Am J Kidney Dis. Aug 1987;10(2):140-3. [Medline].

  29. Wang T, Egbert AL Jr, Aronson PS, et al. Effect of metabolic acidosis on NaCl transport in the proximal tubule. Am J Physiol. Jun 1998;274(6 Pt 2):F1015-9. [Medline].

  30. Wiederkehr MR, Kalogiros J, Krapf R. Correction of metabolic acidosis improves thyroid and growth hormone axes in haemodialysis patients. Nephrol Dial Transplant. May 2004;19(5):1190-7. [Medline].

  31. Wiederseiner JM, Muser J, Lutz T, et al. Acute metabolic acidosis: characterization and diagnosis of the disorder and the plasma potassium response. J Am Soc Nephrol. Jun 2004;15(6):1589-96. [Medline].

 
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