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Metabolic acidosis

Key sources
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).


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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More topics in this section

  • 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.
Consider obtaining close monitoring in patients with diabetic ketoacidosis, ideally in an ICU setting.

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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