Metabolic acidosis medical therapy: Difference between revisions

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=== General Management ===
===General Management===
  ECLS Approach to Management of Metabolic Acidosis
  ECLS Approach to Management of Metabolic Acidosis
{| class="wikitable"
{| class="wikitable"
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|-
|-
|Losses:
|Losses:
|Replace losses (e.g. of fluids and electrolytes) where appropriate. Other supportive care (oxygen administration) is useful. In most cases, IV sodium bicarbonate is NOT necessary, NOT helpful, and may even be harmful so is not generally recommended.
|Replace losses (e.g. fluids and electrolytes) where appropriate. Other supportive care (oxygen administration) is useful. In most cases, IV sodium bicarbonate is not necessary, and may even be harmful so is not generally recommended.
|-
|-
|Specifics:
|Specifics:
|There are often specific problems or complications associated with specific causes or specific cases which require specific management. For example, Ethanol blocking treatment with methanol ingestion; rhabdomyolysis requires management for preventing acute renal failure;  hemodialysis can remove some toxins
|There are often specific problems or complications associated with specific causes or specific cases that require specific management. For example, Ethanol blocking treatment with methanol ingestion; rhabdomyolysis requires management by IV fluids and uricosurics agents for preventing acute renal failure;  hemodialysis can remove some nephrotoxins
|}
|}


=== Specific Treatment: ===
===Specific Treatment:===
Administration of bicarbonates and dialysis is required for metabolic acidosis that is associated with Renal failure.
Administration of bicarbonates and dialysis is required for metabolic acidosis that is associated with Renal failure.


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  Treatment of Diabetic-ketoacidosis
  Treatment of Diabetic-ketoacidosis


* DKA is managed in an intensive care unit during the first day is always advisable
*DKA is managed in an intensive care unit during the first day is always advisable
* Fluid, Insulin and electrolyte replacement are most crucial for DKA management.
*Fluid, Insulin and electrolyte replacement are most crucial for DKA management.
* Correction of fluid loss with intravenous fluids only , Correction of hyperglycemia with insulin, Correction of electrolyte disturbances, particularly potassium loss is < 5.5, Correction of acid-base balance by bicarbonate if <7.1,  Treatment of concurrent infection by antibiotics, if present.
*Correction of fluid loss with intravenous fluids only , Correction of hyperglycemia with insulin, Correction of electrolyte disturbances, particularly potassium loss is < 5.5, Correction of acid-base balance by bicarbonate if <7.1,  Treatment of concurrent infection by antibiotics, if present.


{| class="wikitable"
{| class="wikitable"
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Switch to subcutaneous basal bolus insulin for the following :
Switch to subcutaneous basal bolus insulin for the following :


# able to eat
#able to eat
# glucose <200 mg/dl
#glucose <200 mg/dl
# anion gap <12 mEq/L
#anion gap <12 mEq/L
# serum bicarbonate > 15 mEq/L
#serum bicarbonate > 15 mEq/L
# pH > 7.3
#pH > 7.3


Overlap subcutaneous and IV insulin by 1-2 hours.
Overlap subcutaneous and IV insulin by 1-2 hours.

Revision as of 14:30, 23 January 2021



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Overview

A pH under 7.1 is an emergency, due to the risk of cardiac arrhythmias, and may warrant treatment with intravenous bicarbonate. Bicarbonate is given at 50-100 mmol at a time under scrupulous monitoring of the arterial blood gas readings. This intervention however, is not effective in case of lactic acidosis. If the acidosis is particularly severe and/or there may be intoxication, consultation with the nephrology team is considered useful, as dialysis may clear both the intoxication and the acidosis.


General Management

ECLS Approach to Management of Metabolic Acidosis
ECLS Approach to Management of Metabolic Acidosis
Emergency: intubation and ventilation for airway or ventilatory control; Cardiopulmonary resuscitation: Severe hyperkalemia
Cause: Treat the underlying disorder as the primary therapeutic goal. Consequently, an accurate diagnosis of the cause of metabolic acidosis is very important.
Losses: Replace losses (e.g. fluids and electrolytes) where appropriate. Other supportive care (oxygen administration) is useful. In most cases, IV sodium bicarbonate is not necessary, and may even be harmful so is not generally recommended.
Specifics: There are often specific problems or complications associated with specific causes or specific cases that require specific management. For example, Ethanol blocking treatment with methanol ingestion; rhabdomyolysis requires management by IV fluids and uricosurics agents for preventing acute renal failure; hemodialysis can remove some nephrotoxins

Specific Treatment:

Administration of bicarbonates and dialysis is required for metabolic acidosis that is associated with Renal failure.

Restoration of adequate intravascular volume and proper peripheral perfusion is necessary for metabolic acidosis caused by lactic acidosis.

Treatment of Diabetic-ketoacidosis
  • DKA is managed in an intensive care unit during the first day is always advisable
  • Fluid, Insulin and electrolyte replacement are most crucial for DKA management.
  • Correction of fluid loss with intravenous fluids only , Correction of hyperglycemia with insulin, Correction of electrolyte disturbances, particularly potassium loss is < 5.5, Correction of acid-base balance by bicarbonate if <7.1, Treatment of concurrent infection by antibiotics, if present.
MANAGEMENT OF DKA AND HHS
IV fluids Hight flow 0.9% normal saline is recommended and should be continued until corrected sodium is <135 mg/dl. Switch to .45% normal saline when Sodium >135 mg/dl.

Add dextrose into 0.45% normal saline when serum glucose <200 mg/dl and sodium <135.

Insulin Initiate continuous IV regular insulin infusion

Switch to subcutaneous basal bolus insulin for the following :

  1. able to eat
  2. glucose <200 mg/dl
  3. anion gap <12 mEq/L
  4. serum bicarbonate > 15 mEq/L
  5. pH > 7.3

Overlap subcutaneous and IV insulin by 1-2 hours.

Potassium Add IV potassium if serum potassium <5.2 mEq/L

Hold insulin for serum potassium <3.3 mEq/L

Nearly all patients are potassium depleted, even with hyperkalemia

Bicarbonates Consider for patients with pH<6.9, Bicarbonate<5 and severe hyperkalemia. But mostly it is avoided as it is cause of cerebral edema in children.
phosphate Consider for serum phosphate <1 mg/dl, cardiac dysfunction, or respiratory depression

Monitor serum calcium frequently

Contraindicated medications

Metabolic acidosis is considered an absolute contraindication to the use of the following medications:

References

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