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Pediatric Metabolic Acidosis Treatment & Management

  • Author: Lennox H Huang, MD, FAAP; Chief Editor: Timothy E Corden, MD  more...
 
Updated: Jan 06, 2015
 

Approach Considerations

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 regarding this symptom complex would prevent the physician from obtaining immediate treatment (hemodialysis) for this patient.

Insulin administration is necessary in cases of diabetic ketoacidosis, and restoration of adequate perfusion with crystalloid administration is necessary in cases of dehydration.[6, 7] The same holds true for other diseases, such as renal failure and shock, that lead to metabolic acidosis.

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.

The underlying disease state (eg, diabetes, renal failure) may require diet modification.

A 2009 study concluded that albumin was not more effective than normal saline in initial hydration of dehydrated term infants with metabolic acidosis due to acute diarrhea.[8]

Go to Metabolic Acidosis in Emergency Medicine and Metabolic Acidosis for complete information on these topics.

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Consultations

Consultations depend on the underlying etiology of metabolic acidosis.

Consult a critical care specialist in cases of metabolic acidosis with shock.

Consult with a nephrologist for children with renal failure, who may or may not require dialysis. Consult with a geneticist for inborn errors of metabolism.

Consult with a surgeon if the underlying cause of metabolic acidosis is surgical in nature (necrotizing enterocolitis, malrotation, volvulus, ruptured appendicitis).

Consult with an endocrinologist for children whose metabolic acidosis is caused by diabetic ketoacidosis.

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Bicarbonate Therapy

In instances in which the serum bicarbonate level is only mildly to moderately depressed (>10-12 mEq/L), bicarbonate replacement may not be necessary. If the underlying disease is treated appropriately, the kidneys are able to replenish bicarbonate stores within 3-4 days, unless significant renal dysfunction is present.

In some disease states, the use of bicarbonate therapy is clearly indicated. For patients with chronic renal failure or renal tubular acidosis (RTA), bicarbonate replacement is necessary because of known, ongoing bicarbonate losses. In salicylate intoxication, short-term therapy with bicarbonate to create an alkalemic environment enhances toxin elimination.

Emergent bicarbonate therapy may be warranted in decompensated shock states in patients with a pH of less than 7.15. Studies of human lactic acidosis have generally failed to demonstrate a hemodynamic benefit to bicarbonate therapy.[9] Patients with lactic acidosis from severe asthma exacerbations, however, may benefit from bicarbonate therapy.[10] A survey of pediatric acute care physicians published in 2013 showed that there is a range of opinions regarding the use of emergency bicarbonate therapy in shock and cardiac arrest.[11]

Calculating the amount of bicarbonate replacement necessary must take into account the effect of nonbicarbonate buffers on exogenously administered bicarbonate. Multiply the desired increase in plasma bicarbonate concentration by the apparent volume of distribution and weight. The bicarbonate deficit can be calculated as follows:

(Desired Bicarbonate - Measured Bicarbonate) x Weight (kg) x 0.6

The general recommendation is to replace only half of the total bicarbonate deficit during the first few hours of therapy.

Do not overestimate or overcorrect the bicarbonate deficit. Rapid infusion of bicarbonate for chronic conditions and overcorrection of the metabolic acidosis can lead to complications such as tetany, seizures, and hypokalemia by worsening the preexisting hypocalcemia and hypokalemia.

Doses of bicarbonate exceeding 1 mEq/kg per dose may lead to an alkaline overshoot. For each 0.1 increase in pH, oxygen availability may decrease by 10% because of the shift of the oxygen-hemoglobin dissociation curve to the left.

Parenteral forms of sodium bicarbonate are available as 4% (half strength) or 8% solutions. The sodium load can be significant when multiple bolus doses are administered.

If hypernatremia is a concern, consider continuous infusion of sodium bicarbonate as part of the maintenance intravenous solution. For example, 34 mEq/L of sodium bicarbonate can be added to a 0.22% sodium chloride solution to make up a 0.45% salt solution for maintenance intravenous therapy.

The use of sodium bicarbonate therapy in cases of diabetic ketoacidosis is controversial. A report by Glaser et al stated that patients with diabetic ketoacidosis who were treated with sodium bicarbonate were at increased risk for cerebral edema.[2]

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.

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Thiamine Administration

Thiamine deficiency is a very rare cause of severe lactic acidosis and shock, which is often resistant to inotropic agents and volume resuscitation. Thiamine deficiency should be considered for patients with lactic acidosis and shock on long-term total parenteral nutrition without multivitamins for 2 or more weeks. Thiamine administration rapidly corrects the clinical symptomatology.

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Tromethamine

Tromethamine (also called THAM or tris [hydroxymethyl]-aminomethane) is a buffer that can be used to treat acidosis when concerns exist regarding carbon dioxide accumulation from the metabolism of administered sodium bicarbonate. THAM increases serum bicarbonate predictably:

  • THAM + H 2 CO 3 → THAM-H + HCO 3
  • H 2 CO 3 → CO 2 + H 2 O
  • Dose: 1 mEq/kg
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Hemodialysis and Surgical Care

Hemodialysis

Hemodialysis is an option for correcting a severe metabolic acidosis associated with renal failure or intoxication with methanol or ethylene glycol.[12]

Surgical care

Surgical care may be indicated based on the etiology of metabolic acidosis. Tissue ischemia or necrosis from bowel obstruction or necrotizing enterocolitis, with or without peritonitis, may lead to metabolic acidosis.

Especially in newborns with necrotizing enterocolitis, metabolic acidosis may be the first laboratory abnormality associated with a surgical abdomen.

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Contributor Information and Disclosures
Author

Lennox H Huang, MD, FAAP Associate Professor and Chair, Department of Pediatrics, McMaster University School of Medicine; Chief of Pediatrics, McMaster Children's Hospital

Lennox H Huang, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for Physician Leadership, Canadian Medical Association, Ontario Medical Association, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Margaret A Priestley, MD Associate Professor of Clinical Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania; 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, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

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, Wisconsin Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

G Patricia Cantwell, MD, FCCM Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami, Leonard M Miller School of Medicine; Medical Director, Palliative Care Team, Director, Pediatric Critical Care Transport, Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Manager, FEMA, Urban Search and Rescue, South Florida, Task Force 2; Pediatric Medical Director, Tilli Kids – Pediatric Initiative, Division of Hospice Care Southeast Florida, Inc

G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

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.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
  1. Kraut JA, Madias NE. Metabolic acidosis: pathophysiology, diagnosis and management. Nat Rev Nephrol. 2010 May. 6(5):274-85. [Medline].

  2. Glaser N, Barnett P, McCaslin I, Nelson D, Trainor J, Louie J, 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. 2001 Jan 25. 344(4):264-9. [Medline].

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

  4. Randolph DA, Nolen TL, Ambalavanan N, Carlo WA, Peralta-Carcelen M, Das A, et al. Outcomes of extremely low birthweight infants with acidosis at birth. Arch Dis Child Fetal Neonatal Ed. 2014 Feb 19. [Medline].

  5. Dabelea D, Rewers A, Stafford JM, et al. Trends in the prevalence of ketoacidosis at diabetes diagnosis: the SEARCH for diabetes in youth study. Pediatrics. 2014 Apr. 133(4):e938-45. [Medline]. [Full Text].

  6. Nallasamy K, Jayashree M, Singhi S, et al. Low-dose vs standard-dose insulin in pediatric diabetic ketoacidosis: a randomized clinical trial. JAMA Pediatr. 2014 Nov. 168(11):999-1005. [Medline].

  7. Koves IH, Leu MG, Spencer S, et al. Improving care for pediatric diabetic ketoacidosis. Pediatrics. 2014 Sep. 134(3):e848-56. [Medline].

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

  9. Forsythe SM, Schmidt GA. Sodium bicarbonate for the treatment of lactic acidosis. Chest. 2000 Jan. 117(1):260-7. [Medline].

  10. Manthous CA. Lactic acidosis in status asthmaticus : three cases and review of the literature. Chest. 2001 May. 119(5):1599-602. [Medline].

  11. Parker MJ, Parshuram CS. Sodium bicarbonate use in shock and cardiac arrest: attitudes of pediatric acute care physicians. Crit Care Med. 2013 Sep. 41(9):2188-95. [Medline].

  12. Agarwal B, Kovari F, Saha R, Shaw S, Davenport A. Do Bicarbonate-Based Solutions for Continuous Renal Replacement Therapy Offer Better Control of Metabolic Acidosis than Lactate-Containing Fluids. Nephron Clin Pract. 2011 Feb 23. 118(4):c392-c398. [Medline].

 
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