Pediatric Metabolic Alkalosis Clinical Presentation
- Author: Lennox H Huang, MD, FAAP; Chief Editor: Timothy E Corden, MD more...
Obtain historical data to pinpoint the nature of the disease causing metabolic alkalosis. Ask about vomiting, other gastric fluid loss, and diuretic use. Loss of gastric fluid and HCl due to vomiting is the most common cause of metabolic alkalosis. Vomiting may be caused by pyloric stenosis or ulcers. Occasionally, it may be self-induced. Significant gastric fluid loss can occur via long-term nasogastric (NG) tube drainage.
Diuretic use may lead to increased chloride losses. It may also result in potassium loss, and hypokalemia may lead to metabolic alkalosis.
Obtain information about specific disease states such as primary hyperaldosteronism, reninism, hyperglucocorticoidism, Bartter syndrome, and deoxycorticosterone (DOC) excess syndromes.[5, 6]
Signs and symptoms observed with metabolic alkalosis usually relate to the specific disease process that caused the acid-base disorder. Increased neuromuscular excitability (eg, from hypocalcemia) sometimes causes tetany or seizures. Generalized weakness may be noted if the patient also has hypokalemia.
Patients who develop metabolic alkalosis from vomiting can have symptoms related to severe volume contraction, with signs of dehydration that include tachycardia, dry mucous membranes, decreased skin turgor, postural hypotension, poor peripheral perfusion, and weight loss.
Although diarrhea typically produces a hyperchloremic metabolic acidosis, diarrheal stools may rarely contain significant amounts of chloride, as in the case of congenital chloride diarrhea. Children with this condition present at birth with watery diarrhea, metabolic alkalosis, and hypovolemia.
Weight gain and hypertension may accompany metabolic alkalosis that results from a hypermineralocorticoid state.
Severe metabolic alkalosis can lead to hypoventilation; the resultant hypoxemia is compounded by a shift of the oxygen-hemoglobin dissociation curve to the left. In extreme cases, hypoventilation may be severe enough to require mechanical ventilation or to interfere with weaning from current mechanical ventilation.
Intracellular shift of potassium in severe alkalemia may lead to life-threatening arrhythmias or cardiac arrest.
Caltik A, Akyuz SG, Erdogan O, Bulbul M, Demircin G. Rare presentation of cystinosis mimicking Bartter's syndrome: reports of two patients and review of the literature. Ren Fail. 2010 Jan. 32(2):277-80. [Medline].
Hodgkin JE, Soeprono FF, Chan DM. Incidence of metabolic alkalemia in hospitalized patients. Crit Care Med. 1980 Dec. 8(12):725-8. [Medline].
van Thiel RJ, Koopman SR, Takkenberg JJ, Ten Harkel AD, Bogers AJ. Metabolic alkalosis after pediatric cardiac surgery. Eur J Cardiothorac Surg. 2005 Aug. 28(2):229-33. [Medline].
Anderson LE, Henrich WL. Alkalemia-associated morbidity and mortality in medical and surgical patients. South Med J. 1987 Jun. 80(6):729-33. [Medline].
Fretzayas A, Gole E, Attilakos A, Daskalaki A, Nicolaidou P, Papadopoulou A. Expanding the spectrum of genetic mutations in antenatal Bartter syndrome type II. Pediatr Int. 2013 Jun. 55(3):371-3. [Medline].
Ishimori S, Kaito H, Matsunoshita N, Otsubo H, Hashimoto F, Ninchoji T, et al. SLC26A3 gene analysis in patients with Bartter and Gitelman syndromes and the clinical characteristics of patients with unidentified mutations. Kobe J Med Sci. 2013 Apr 18. 59(2):E36-43. [Medline].
Mathew JT, Bio LL. Injectable ammonium chloride used enterally for the treatment of persistent metabolic alkalosis in three pediatric patients. J Pediatr Pharmacol Ther. 2012 Jan. 17(1):98-103. [Medline]. [Full Text].
Buchanan IB, Campbell BT, Peck MD, Cairns BA. Chest wall necrosis and death secondary to hydrochloric acid infusion for metabolic alkalosis. South Med J. 2005 Aug. 98(8):822-4. [Medline].
Moviat M, Pickkers P, van der Voort PH, van der Hoeven JG. Acetazolamide-mediated decrease in strong ion difference accounts for the correction of metabolic alkalosis in critically ill patients. Crit Care. 2006 Feb. 10(1):R14. [Medline].
Moffett BS, Moffett TI, Dickerson HA. Acetazolamide therapy for hypochloremic metabolic alkalosis in pediatric patients with heart disease. Am J Ther. 2007 Jul-Aug. 14(4):331-5. [Medline].
Andrews MG, Johnson PN, Lammers EM, Harrison DL, Miller JL. Acetazolamide in critically ill neonates and children with metabolic alkalosis. Ann Pharmacother. 2013 Sep. 47(9):1130-5. [Medline].
Bhardwaj S, Pandit D, Sinha A, Hari P, Cheong HI, Bagga A. Congenital chloride diarrhea - novel mutation in SLC26A3 gene. Indian J Pediatr. 2015 Dec 5. [Medline].
Heble DE Jr, Oschman A, Sandritter TL. Comparison of arginine hydrochloride and acetazolamide for the correction of metabolic alkalosis in pediatric patients. Am J Ther. 2014 Nov 6. [Medline].