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Metabolic acidosis

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The following summarized guidelines for the evaluation and management of metabolic acidosis are prepared by our editorial team based on guidelines from the French Society of Emergency Medicine (SFMU/SRLF 2019).
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Guidelines

1.Diagnostic investigations

Laboratory testing: consider obtaining arterial blood gas measurement in patients with decreased plasma bicarbonate level in order to:
eliminate respiratory alkalosis
confirm the diagnosis of metabolic acidosis
test for mixed acidosis
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2.Respiratory support

Mechanical ventilation: consider increasing respiratory frequency without inducing intrinsic PEEP, with a maximum of 35 cycles/min and/or a tidal volume up to 8 mL/kg of body mass, and by monitoring plateau pressure for compensating acidemia.
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3.Medical management

Sodium bicarbonate: consider administering sodium bicarbonate to compensate for gastrointestinal or renal base loss in patients with poor clinical tolerance.
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  • Insulin

4.Inpatient care

Inpatient monitoring
Consider monitoring the increase in blood lactate levels in the first hours of management to assess the response to treatment.
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Consider obtaining close monitoring in patients with diabetic ketoacidosis, ideally in an ICU setting.
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5.Therapeutic procedures

Renal replacement therapy: consider performing RRT in patients with shock and/or acute renal insufficiency if the pH ≤ 7.15 in the absence of severe respiratory acidosis and despite appropriate treatment.
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