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

Alkalosis, Metabolic: Differential Diagnoses & Workup

Author: Lennox H Huang, MD, Associate Clinical Chair, Assistant Professor, Department of Pediatrics, McMaster University; Deputy Chief of Pediatrics, McMaster Children's Hospital
Coauthor(s): 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: Aug 13, 2008

Differential Diagnoses

Alkalosis, Metabolic
Bartter Syndrome
Cystic Fibrosis
Pyloric Stenosis, Hypertrophic

Other Problems to Be Considered

Liddle syndrome
Primary aldosteronism
Hyperglucocorticoidism
DOC excess syndromes
Gastric fluid losses
Potassium depletion
Congenital chloride diarrhea

Workup

Laboratory Studies

  • Measurement of blood gas and serum electrolyte levels, including calcium, are the essential laboratory studies necessary for initial evaluation of metabolic alkalosis. Blood gas measurement shows elevated pH with a high HCO3 level. With compensation, the PCO2 level may also be near the reference range or elevated. Serum electrolyte levels may show evidence of hypokalemia, hypercalcemia, hypochloremia, or hyponatremia.
  • Spot urine chloride
    • Urine chloride level of less than 10 mEq/L indicates chloride-responsive metabolic alkalosis.
    • Urine chloride level of more than 20 mEq/L indicates chloride-resistant metabolic alkalosis.
  • Diagnostic indicators for specific disease states
    • Primary aldosteronism - Metabolic alkalosis, hypokalemia, urine chloride level of more than 20 mEq/L, persistently elevated aldosterone levels despite controlled sodium chloride (NaCl) intake of 12-15 g daily for 5 days
    • Cushing syndrome - Hypersecretion of cortisol
    • Primary reninism - Usually results from renovascular disease with hypertension
    • Bartter syndrome - Hypokalemic metabolic alkalosis with secondary hyperaldosteronism and with renal potassium and chloride wasting
    • Milk-alkali syndrome - Excessive oral intake of calcium, vitamin D metabolites, and absorbable alkali (Metabolic alkalosis is usually accompanied by hypercalcemia.)
    • Pyloric stenosis - Marked hypochloremia (due to loss of HCl in gastric contents) and metabolic alkalosis, generally observed in male infants aged approximately 6-12 weeks (Children present with protracted vomiting and frequently have significant dehydration and cachexia.)

More on Alkalosis, Metabolic

Overview: Alkalosis, Metabolic
Differential Diagnoses & Workup: Alkalosis, Metabolic
Treatment & Medication: Alkalosis, Metabolic
Follow-up: Alkalosis, Metabolic
References
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References

  1. Hodgkin JE, Soeprono FF, Chan DM. Incidence of metabolic alkalemia in hospitalized patients. Crit Care Med. Dec 1980;8(12):725-8. [Medline].

  2. 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. Feb 2006;10(1):R14. [Medline].

  3. Moffett BS, Moffett TI, Dickerson HA. Acetazolamide therapy for hypochloremic metabolic alkalosis in pediatric patients with heart disease. Am J Ther. Jul-Aug 2007;14(4):331-5. [Medline].

  4. 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].

  5. Finberg L, Kravath RE, Hellerstein S. Metabolic Alkalosis. In: Water and Electrolytes in Pediatrics: Physiology, Pathophysiology, and Treatment. Philadelphia, Pa: WB Saunders; 1993:97-98.

  6. Galla JH. Metabolic alkalosis. J Am Soc Nephrol. Feb 2000;11(2):369-75. [Medline].

  7. Kokko JP, Tannen RL, eds. Metabolic Alkalosis. In: Fluids and Electrolytes. 1990. Philadelphia, Pa: WB Saunders; 356-376.

  8. Maxwell MH, Kleeman CR, eds. Metabolic Alkalosis. In: Clinical Disorders of Fluid and Electrolyte Metabolism. New York, NY: McGraw-Hill; 1994:213-220.

  9. 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].

  10. Omron EM. Metabolic alkalosis and cystic fibrosis. Chest. Mar 2004;125(3):1169; author reply 1169-70. [Medline].

  11. Palmer BF, Alpern RJ. Metabolic alkalosis. J Am Soc Nephrol. Sep 1997;8(9):1462-9. [Medline].

  12. Shapiro BA, Harrison RA, Cane RD. Clinical application of blood gases. St. Louis, Mo: Mosby; 1989.

  13. Siberry GK, Iannone R. Formulary. In: The Harriet Lane Handbook: A Manual for Pediatric House Officers. St. Louis, Mo: Mosby; 2000:616, 629.

  14. van Thiel RJ, Koopman SR, Takkenberg JJ, Ten Harkel AD, Bogers AJ. Metabolic alkalosis after pediatric cardiac surgery. Eur J Cardiothorac Surg. Aug 2005;28(2):229-33. [Medline].

  15. [Best Evidence] Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. Jun 15 2006;354(24):2564-75. [Medline].

  16. Wong HR, Chundu KR. Metabolic alkalosis in children undergoing cardiac surgery. Crit Care Med. Jun 1993;21(6):884-7. [Medline].

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Further Reading

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Keywords

metabolic alkalosis, plasma bicarbonate, HCO3, acid-base abnormality, metabolic acidosis, chloride-responsive metabolic alkalosis, chloride-resistant metabolic alkalosis, primary aldosteronism, hypoxemia, arteriolar constriction, hypokalemia, vomiting, pyloric stenosis, primary hyperaldosteronism, reninism, hyperglucocorticoidism, Bartter syndrome, deoxycorticosterone excess syndromes, hypertension, hypermineralocorticoid state, cystic fibrosis, primary aldosteronism, Liddle syndrome, anorexia nervosa, hyperglucocorticoidism, milk-alkali syndrome, hypercalcemia, hypochloremia, hyponatremia

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Contributor Information and Disclosures

Author

Lennox H Huang, MD, Associate Clinical Chair, Assistant Professor, Department of Pediatrics, McMaster University; Deputy Chief of Pediatrics, McMaster Children's Hospital
Lennox H Huang, MD is a member of the following medical societies: American Academy of Pediatrics, Canadian Medical Association, Ontario Medical Association, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

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 broker recommendation; Avanir Pharma Stock Investment from broker recommendation

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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