What are the symptoms and treatment of acidosis?

Symptoms and Treatment of Acidosis

Acidosis is characterized by specific symptoms that vary by type (respiratory or metabolic) and requires targeted treatment based on severity, underlying cause, and pH level.

Types of Acidosis

Acidosis is defined as a blood pH below 7.35 and can be classified into two main types:

1. Respiratory Acidosis

   • Caused by increased arterial partial pressure of carbon dioxide (CO₂)
   • Results from alveolar hypoventilation
   • Can be acute or chronic 1

2. Metabolic Acidosis

   • Caused by increased acid production, decreased acid excretion, or bicarbonate loss
   • Can be further classified based on anion gap 1, 2

Symptoms of Acidosis

Common Symptoms

• Confusion and altered mental status
• Fatigue
• Shortness of breath/Kussmaul respirations (deep, rapid breathing)
• Headache
• Nausea and vomiting
• Weakness

Specific Symptoms by Type

Respiratory Acidosis:

• Drowsiness progressing to stupor
• Tremors
• Myoclonic jerks
• Asterixis (flapping tremor)
• Papilledema in severe cases 3

Metabolic Acidosis:

• Abdominal pain
• Shock-like state in severe cases
• Cardiac arrhythmias
• Decreased cardiac contractility
• Insulin resistance 1, 2

Special Cases

Diabetic Ketoacidosis:

• Fruity breath odor
• Polyuria, polydipsia
• Dehydration
• Abdominal pain 1

Lactic Acidosis:

• Signs of tissue hypoperfusion
• Tachycardia
• Hypotension 1, 4

D-Lactic Acidosis (in short bowel patients):

• Confusion
• Slurred speech
• Ataxia
• Occurs after carbohydrate ingestion 1

Diagnostic Approach

1. Blood Gas Analysis:

   • Arterial pH < 7.35 indicates acidosis
   • PaCO₂ > 45 mmHg suggests respiratory component
   • Bicarbonate < 22 mEq/L suggests metabolic component 1

2. Calculate Anion Gap:

   • Normal: 8-12 mEq/L
   • Elevated in metabolic acidosis due to ketoacidosis, lactic acidosis, renal failure, toxins
   • Normal in hyperchloremic metabolic acidosis 2

3. Additional Tests Based on Suspected Cause:

   • Serum lactate
   • Serum ketones
   • Renal function tests
   • Toxicology screen
   • Electrolytes 4

Treatment Approach

General Principles

1. Address the Underlying Cause:

   • This is the primary treatment goal for all types of acidosis 5

2. Supportive Care:

   • Ensure adequate oxygenation
   • Maintain tissue perfusion
   • Correct fluid deficits 5

Specific Treatments by Type

Respiratory Acidosis:

• Improve ventilation (primary treatment)
• Noninvasive or invasive ventilatory support for acute cases
• Treat underlying cause (COPD, asthma, neuromuscular disorders)
• Sodium bicarbonate is generally not recommended 3, 6

Metabolic Acidosis:

1. Severe Acidosis (pH < 7.2):

   • Consider sodium bicarbonate therapy
   • Dosing: Initially 1-2 vials (44.6-100 mEq) IV, may continue at 50 mL every 5-10 minutes as needed
   • Monitor arterial blood gases 5, 7

2. Specific Conditions:

   • Diabetic Ketoacidosis: Insulin therapy and fluid resuscitation (not bicarbonate) 5
   • Lactic Acidosis: Improve tissue perfusion and treat underlying cause 5, 4
   • Renal Failure: Consider dialysis if indicated 5
   • Chronic Kidney Disease with persistent acidosis: Oral sodium bicarbonate 2-4 g/day 5

Cautions with Bicarbonate Therapy

• Not recommended for lactic acidosis with pH ≥ 7.15
• Can cause sodium and fluid overload
• May increase lactate and PaCO₂
• Can decrease serum ionized calcium
• May cause paradoxical intracellular acidosis 5, 4

Special Considerations

1. D-Lactic Acidosis in Short Bowel Syndrome:

   • Restrict mono and oligosaccharides
   • Encourage slowly digestible polysaccharides
   • Thiamine supplements
   • Broad-spectrum antibiotics 1

2. Hyperammonaemic Acidosis:

   • May occur in short bowel patients
   • Consider arginine supplementation 1

3. Chronic Respiratory Acidosis:

   • Compensatory increase in bicarbonate expected
   • Treatment focuses on underlying cause rather than bicarbonate administration 1, 3

Monitoring Response to Treatment

• Serial arterial blood gases
• Electrolytes
• Clinical symptoms
• Hemodynamic parameters
• Cardiac rhythm 5, 7

By promptly identifying and treating acidosis based on its type and underlying cause, clinicians can improve outcomes and reduce complications associated with this serious acid-base disorder.