metabolic-acidosis

Initial workup (NEJM 2014;371:1434)

CPS Metabolic Acidosis: Overview

• ✓ anion gap
• Etiologies-of-AG-Metabolic-Acidosis
• Workup-for-AG-metabolic-acidosis (AJKD 2021;78:A16)
• Ingestions-caused-metabolic-acidosis
• Etiologies of Non-AG Metabolic Acidosis
• Workup for non-AG metabolic acidosis
• Renal tubular acidoses

Figure 4-2 Approach to metabolic acidosis

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Treatment of severe metabolic acidoses (pH <7.2) (Nat Rev Nephrol 2012;8:589)

• DKA: insulin, IVF, K repletion (NEJM 2015;372:546); AKA: dextrose, IVF, replete K, Mg, PO4
• Lactic acidosis: treat underlying condition, avoid vasoconstrictors, avoid “Type B” meds
• Renal failure: hemodialysis
• Methanol & ethylene glycol: fomepizole (20 mg/dL), vit. B1 & B6 (ethylene glycol), folate (methanol), dialysis (if AKI, VS unstable, vision Δ or >50 mg/dL) (NEJM 2018;378:270)
• Alkali therapy: if pH <7.1 or <7.2 and co-existing AKI (may ↓ mortality; Lancet 2018;392:31)
• NaHCO3: amps by IV push or infusion of three 50-mmol amps in 1 L D5W if less urgent
• Uptodate: Sodium bicarbonate Can estimate mmol of HCO3 needed as [desired-current HCO3]serum × wt (kg) × 0.4 Side effects: ↑ volume, ↑ Na, ↓ ICa, ↑ PaCO2 (& ∴ intracellular acidosis; ∴ must ensure adequate ventilation to blow off CO2)