Pediatric Metabolic Alkalosis Workup

  • Author: Lennox H Huang, MD; Chief Editor: Timothy E Corden, MD   more...
 
Updated: Jun 8, 2011
 

Approach Considerations

Measurements of blood gas and serum electrolyte levels, including calcium, are the essential laboratory studies necessary for initial evaluation of metabolic alkalosis. An algorithm for metabolic alkalosis is shown in the image below.

Algorithm for metabolic alkalosis. Algorithm for metabolic alkalosis.
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Blood Gas Measurement, Serum Electrolyte levels, and Spot Urine Chloride

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.

A urine chloride level of less than 10 mEq/L indicates chloride-responsive metabolic alkalosis. A urine chloride level of more than 20 mEq/L indicates chloride-resistant metabolic alkalosis.

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Diagnostic Indicators for Specific Disease States

Patients with primary aldosteronism have metabolic alkalosis, hypokalemia, a urine chloride level of more than 20 mEq/L, and persistently elevated aldosterone levels despite controlled sodium chloride (NaCl) intake of 12-15 g daily for 5 days.

Cushing syndrome is marked by hypersecretion of cortisol.

Primary reninism usually results from renovascular disease with hypertension.

Bartter syndrome manifests as hypokalemic metabolic alkalosis with secondary hyperaldosteronism and with renal potassium and chloride wasting.

Milk-alkali syndrome results from excessive oral intake of calcium, vitamin D metabolites, and absorbable alkali. Metabolic alkalosis in these patients is usually accompanied by hypercalcemia.

Pyloric stenosis causes marked hypochloremia (due to loss of HCl in gastric contents) and metabolic alkalosis. It is generally observed in male infants aged approximately 6-12 weeks. These patients present with protracted vomiting and frequently have significant dehydration and cachexia.

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Contributor Information and Disclosures
Author

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

Lennox H Huang, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Physician Executives, 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.

Specialty Editor Board

G Patricia Cantwell, MD, FCCM  Professor of Clinical Pediatrics, University of Miami, Leonard M Miller School of Medicine; Chief, Division of Pediatric Critical Care Medicine, Medical Manager, Urban Search & Rescue, South Florida TF-2, Medical Director, Holtz Children's Hospital Palliative Care Team, Medical Director, Tilli Kids – Pediatric Initiative of Hospice Care of SE Florida, Director, Pediatric Critical Care Transport, Holtz Children's Hospital/Jackson Memorial Hospital

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.

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.

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.

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.

References

  1. 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. Jan 2010;32(2):277-80. [Medline].

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

  3. 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].

  4. Anderson LE, Henrich WL. Alkalemia-associated morbidity and mortality in medical and surgical patients. South Med J. Jun 1987;80(6):729-33. [Medline].

  5. Buchanan IB, Campbell BT, Peck MD, Cairns BA. Chest wall necrosis and death secondary to hydrochloric acid infusion for metabolic alkalosis. South Med J. Aug 2005;98(8):822-4. [Medline].

  6. 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].

  7. 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].

 
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Algorithm for metabolic alkalosis.
 
 
 
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