1. First-Line Therapies for Metabolic Acidosis

Severe metabolic acidosis, typically defined by an arterial pH below 7.10, is a medical emergency that requires targeted buffering strategies and careful fluid selection to avoid iatrogenic complications like hyperchloremia.

A. Sodium Bicarbonate

• Mechanism of Action: Provides an exogenous source of bicarbonate (HCO₃⁻) to buffer excess hydrogen ions (H⁺) in the extracellular space. The resulting carbonic acid (H₂CO₃) is converted to CO₂ and water, requiring adequate ventilation to excrete the CO₂ load.
• Indications:
  • Severe metabolic acidosis with an arterial pH < 7.10.
  • Acute kidney injury (Stage 2 or higher) with metabolic acidosis.
  • Certain toxic ingestions, such as salicylates, methanol, or phenobarbital, to enhance elimination.
• Dosing:
  • Calculate the bicarbonate deficit: Deficit (mEq) = 0.5 × body weight (kg) × (desired HCO₃⁻ – measured HCO₃⁻).
  • Administer ⅓ to ½ of the calculated dose as a slow infusion over 1–2 hours, then re-evaluate. The goal is to titrate therapy to a safer pH range (e.g., 7.25–7.30), not to fully normalize the pH.
• Monitoring: Requires close monitoring of arterial blood gases (ABG) every 4–6 hours, serum electrolytes (Na⁺, K⁺, Ca²⁺, Cl⁻), and volume status.
• Contraindications/Warnings: Avoid in patients with uncorrected respiratory acidosis unless mechanical ventilation can be adjusted. Use with extreme caution in patients with pulmonary edema or uncontrolled hypertension due to the significant sodium and fluid load.

B. Balanced Crystalloids versus 0.9% Saline

• Strong Ion Difference (SID): Balanced fluids like Lactated Ringer’s or Plasma-Lyte have a SID closer to physiologic levels (~24–28 mEq/L), whereas 0.9% saline has a SID of 0. This difference is key to preventing iatrogenic acidosis.
• Clinical Benefits: Large-volume resuscitation with 0.9% saline can induce a hyperchloremic metabolic acidosis. Studies have shown that using balanced crystalloids is associated with a lower incidence of this complication, as well as reduced rates of acute kidney injury (AKI) and need for renal replacement therapy (RRT).

2. Adjunctive Therapies for Metabolic Alkalosis

Management of metabolic alkalosis primarily involves correcting the underlying cause, repleting volume with chloride-rich fluids, and correcting hypokalemia. When these measures are insufficient, adjunctive pharmacotherapies may be considered.

A. Acetazolamide

• Mechanism: A carbonic anhydrase inhibitor that blocks bicarbonate reabsorption in the proximal renal tubule, promoting its excretion in the urine.
• Indications: Primarily for chloride-responsive metabolic alkalosis, such as that induced by diuretics or occurring after correction of chronic hypercapnia, especially in the context of ventilator weaning.
• Dosing: A typical starting dose is 500 mg IV once, with subsequent doses guided by the response in pH and electrolytes.
• Pitfalls: Efficacy is significantly reduced in the presence of hypokalemia, which perpetuates alkalosis by promoting renal H⁺ excretion and K⁺ reabsorption. Always correct hypokalemia before or concurrently with acetazolamide administration.

B. Thiazide Diuretics

• Mechanism: Blocks the Na⁺–Cl⁻ symporter in the distal convoluted tubule. While typically associated with causing alkalosis, in specific volume-overloaded states, they can induce a mild volume contraction and enhance chloride delivery to the collecting duct, facilitating bicarbonate excretion.
• Indications: Used cautiously in volume-overloaded patients with chloride-responsive metabolic alkalosis.
• Dosing: Low doses such as hydrochlorothiazide 12.5–25 mg PO daily are used, with adjustments for renal function.
• Pitfalls: Carry a significant risk of electrolyte disturbances, including hyponatremia and hypokalemia, which can worsen the underlying metabolic state.

3. Pharmacokinetic and Pharmacodynamic Considerations

Critical illness profoundly alters drug handling. These principles are especially important when titrating therapies for acid-base disorders, which are themselves dynamic processes.

• Increased Volume of Distribution: Systemic inflammation, capillary leak, and aggressive fluid resuscitation expand the volume into which drugs like sodium bicarbonate distribute. This may necessitate larger initial doses to achieve a therapeutic effect.
• Altered Protein Binding: Hypoalbuminemia is common in critical illness and reduces the body’s non-bicarbonate buffer capacity. This can magnify the pH shifts caused by acid-base disturbances.
• Perfusion-Dependent CO₂ Clearance: In shock states, poor tissue perfusion slows the delivery of CO₂ to the lungs for excretion. The rate of bicarbonate infusion must be matched to the patient’s ventilatory and circulatory capacity to avoid CO₂ accumulation.

4. Renal Replacement Therapy and Citrate Anticoagulation

When pharmacologic interventions fail or when severe AKI is present, RRT offers a powerful method for continuous acid-base control. However, the choice of anticoagulation can influence this balance.

• Modality Selection: Continuous renal replacement therapy (CRRT) is preferred for hemodynamically unstable patients, providing slow, continuous correction. Intermittent hemodialysis (HD) can be used for more stable patients.
• Citrate Anticoagulation: Regional citrate anticoagulation is a common method where citrate is infused into the blood before it enters the filter. Citrate chelates calcium, preventing clotting within the circuit. It is then metabolized in the liver and muscle back to bicarbonate. This metabolic conversion poses a risk of iatrogenic metabolic alkalosis if citrate accumulates (e.g., in severe liver failure).

5. Route of Administration and Delivery Devices

Safe administration of potent electrolytes is critical to avoid iatrogenic harm.

• Sodium Bicarbonate: As a hypertonic solution, it should be administered via a central venous catheter or a large-bore peripheral IV to minimize the risk of phlebitis and extravasation injury. Precise titration is essential.
• Balanced Crystalloids: These are generally isotonic and can be safely infused through any standard large-bore peripheral line. Be mindful of compatibility with other infusions and blood products, as some balanced fluids contain calcium (e.g., Lactated Ringer’s), which can cause clotting in blood tubing.

6. Serial ABG Monitoring Plan

A structured monitoring plan is crucial for guiding therapy and ensuring patient safety.

• Frequency: Obtain a baseline ABG before initiating therapy. During active correction, repeat sampling every 4–6 hours or after any major intervention (e.g., a bicarbonate bolus or a significant change in infusion rate).
• Key Parameters: Monitor the full acid-base panel: pH, PaCO₂, HCO₃⁻, base excess, and lactate.
• Escalation Criteria: If the pH remains below 7.20 despite two calculated doses of sodium bicarbonate, this may indicate refractory acidosis, and escalation to RRT should be strongly considered.
• De-escalation Criteria: Once the pH rises above 7.30 and the serum bicarbonate is greater than 20 mEq/L, the infusion can be tapered and discontinued.

7. Pharmacoeconomics and Safety Profiles

The choice between pharmacologic management and RRT involves a trade-off between cost, resource intensity, and safety profiles.