eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Critical Care

Acidosis, Metabolic: Follow-up

Author: Margaret A Priestley, MD, Assistant Professor of Clinical Anesthesiology and Critical Care, University of Pennsylvania School of Medicine; Clinical Director, Pediatric Intensive Care Unit, The Children's Hospital of Philadelphia
Contributor Information and Disclosures

Updated: Jun 25, 2009

Follow-up

Further Inpatient Care

  • The priority is to determine the underlying etiology that causes the metabolic acidosis; the metabolic acidosis is a symptom rather than a disease.
  • Further inpatient management, including critical care, depends on the underlying etiology. Children with inherited metabolic abnormalities, poisoning, or renal failure may require hemodialysis. Children with lactic acidosis caused by circulatory failure, thiamine deficiency, or septic shock require appropriate supportive care that first addresses the ABCs and potentially includes fluid resuscitation, inotropic support, and antibiotics. Children with diabetic ketoacidosis must be treated with appropriate fluid and electrolyte therapy and insulin.

Transfer

  • Transfer patients to an ICU or pediatric hospital depending on the nature of the disease that led to metabolic acidosis and the need for subspecialty care.

Complications

  • Untreated, severe metabolic acidosis can lead to myocardial depression, seizures, shock, and multiorgan failure.
  • Bicarbonate administration during treatment for diabetic ketoacidosis has been associated with an increased risk of cerebral edema.

Prognosis

  • Patient outcome depends on the nature of the disease process that led to metabolic acidosis. Children with an inherited metabolic disease require long-term specialized management and a special diet. Those with diabetic ketoacidosis need lifelong insulin administration and an appropriate diet. Those who develop a metabolic acidosis secondary to a toxic ingestion or poisoning have the potential to recover without long-standing consequences.
  • Guidelines regarding metabolic acidosis and growth in children have been established.3

Miscellaneous

Medicolegal Pitfalls

  • Inability to recognize the etiology of metabolic acidosis can lead to failure to treat the basic disease process. For example, a child who ingests windshield-wiper fluid containing ethylene glycol may present with severe metabolic acidosis, hypoglycemia, and coma. Failure to be adequately suspicious about this symptom complex would prevent the physician from obtaining immediate treatment (hemodialysis) for this patient. The same holds true for other diseases such as renal failure and shock, which lead to metabolic acidosis.
  • If the child requires tracheal intubation secondary to respiratory muscle fatigue or mental status alterations, the practitioners must remember to maintain a high minute ventilation if the metabolic acidosis is still severe when the intervention is performed. Aiming for a PaCO2 expected by the Winter formula is appropriate.

Special Concerns

  • In newborns, frequent administration of hypertonic solutions such as sodium bicarbonate have led to intracranial hemorrhage resulting from hyperosmolality and resultant fluid shifts from the intracellular space.
  • Rapid infusion of sodium bicarbonate to correct metabolic acidosis has led to paradoxical CNS acidosis in animal studies. The cause is believed to be sodium bicarbonate dissociating into carbon dioxide and water; carbon dioxide rapidly crosses the blood-brain barrier, but bicarbonate does not, leading to CNS acidosis.
 


More on Acidosis, Metabolic

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Differential Diagnoses & Workup: Acidosis, Metabolic
Treatment & Medication: Acidosis, Metabolic
Follow-up: Acidosis, Metabolic
Multimedia: Acidosis, Metabolic
References
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References

  1. Glaser N, Barnett P, McCaslin I, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. N Engl J Med. Jan 25 2001;344(4):264-9. [Medline].

  2. Han JJ, Yim HE, Lee JH, et al. Albumin versus normal saline for dehydrated term infants with metabolic acidosis due to acute diarrhea. J Perinatol. Jun 2009;29(6):444-7. [Medline].

  3. [Guideline] Hodson E. Metabolic acidosis and growth in children. Nephrology. Dec 2005;10(S5):S221-2. [Full Text].

  4. Casaletto JJ. Differential diagnosis of metabolic acidosis. Emerg Med Clin North Am. Aug 2005;23(3):771-87, ix. [Medline].

  5. Fall PJ. A stepwise approach to acid-base disorders. Practical patient evaluation for metabolic acidosis and other conditions. Postgrad Med. Mar 2000;107(3):249-50, 253-4, 257-8 passim. [Medline].

  6. Fattal-Valevski A, Kesler A, Sela BA, et al. Outbreak of life-threatening thiamine deficiency in infants in Israel caused by a defective soy-based formula. Pediatrics. Feb 2005;115(2):e233-8. [Medline].

  7. Levraut J, Grimaud D. Treatment of metabolic acidosis. Curr Opin Crit Care. Aug 2003;9(4):260-5. [Medline].

  8. Naka T, Bellomo R. Bench-to-bedside review: treating acid-base abnormalities in the intensive care unit--the role of renal replacement therapy. Crit Care. Apr 2004;8(2):108-14. [Medline].

  9. Szaflarski N, Hanson CW 3rd. Metabolic acidosis. AACN Clin Issues. Aug 1997;8(3):481-96. [Medline].

  10. Thauvin-Robinet C, Faivre L, Barbier ML, Chevret L, Bourgeois J, Netter JC. Severe lactic acidosis and acute thiamin deficiency: a report of 11 neonates with unsupplemented total parenteral nutrition. J Inherit Metab Dis. 2004;27(5):700-4. [Medline].

  11. Uchida H, Yamamoto H, Kisaki Y, Fujino J, Ishimaru Y, Ikeda H. D-lactic acidosis in short-bowel syndrome managed with antibiotics and probiotics. J Pediatr Surg. Apr 2004;39(4):634-6. [Medline].

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Further Reading

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Keywords

metabolic acidosis, bicarbonate, anions, cations, hydrogen, anion gap, anion gap acidosis, normal anion gap metabolic acidosis, renal tubular acidosis, RTA, acid-base disorder, plasma bicarbonate, plasma bicarbonate level, acidemia, respiratory acidosis, respiratory failure, myocardial depression, diarrhea, inborn error of metabolism, neonatal sepsis, hypoplastic left heart syndrome, renal insufficiency, renal tubular acidosis, RTA, failure to thrive, hypoglycemia, hyperammonemia, treatment, diagnosis

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Contributor Information and Disclosures

Author

Margaret A Priestley, MD, Assistant Professor of Clinical Anesthesiology and Critical Care, University of Pennsylvania School of Medicine; Clinical Director, Pediatric Intensive Care Unit, The Children's Hospital of Philadelphia
Margaret A Priestley, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Medical Editor

G Patricia Cantwell, MD, Associate Clinical Professor, Department of Pediatrics, University of Miami; Director of Pediatric Critical Care Medicine, Miller School of Medicine, Jackson Children's Hospital
G Patricia Cantwell, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Barry J Evans, MD, Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center
Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital
Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians
Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Timothy E Corden, MD, Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin
Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society
Disclosure: Nothing to disclose.

 
 
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