Sodium Acetate Should Not Be Added to Maintenance Fluids for This Patient
The evidence-based approach for this 15-month-old with diarrheal dehydration and metabolic acidosis (bicarbonate 11) is to use oral rehydration solution or intravenous saline for rehydration—not to add sodium acetate to maintenance fluids. The metabolic acidosis will correct with appropriate fluid resuscitation alone.
Why Sodium Acetate Is Not Indicated
Metabolic acidosis from diarrheal dehydration corrects spontaneously with adequate fluid resuscitation, without requiring alkali supplementation in the vast majority of cases 1, 2.
Oral rehydration solutions containing citrate (a bicarbonate precursor) are as effective as bicarbonate-containing solutions for correcting acidosis in diarrhea, demonstrating that the acidosis resolves with rehydration itself 3.
Only oliguric patients with severe acidosis require physiological doses of bicarbonate to correct blood pH to 7.25—this is the exception, not the rule 1.
The Correct Treatment Approach
Initial Rehydration Phase
For mild-to-moderate dehydration: Use oral rehydration solution containing 45-75 mEq/L sodium at 50-100 mL/kg over 2-4 hours 4, 5, 1.
For severe dehydration: Use intravenous 0.9% saline at 60-100 mL/kg over the first 2-4 hours to restore circulation, then transition to oral rehydration 1.
The acidosis will correct during this rehydration phase as tissue perfusion improves and lactate is metabolized 1, 2.
Maintenance Phase (After Rehydration)
Once rehydration is complete, maintenance fluids should be 5% dextrose in 0.2% saline with 20 mEq/L KCl—no sodium acetate or bicarbonate is added 1.
For isonatremic dehydration (most common with viral diarrhea), use 5% dextrose in 0.45% saline with 20 mEq/L KCl over 24 hours 1.
Replace ongoing diarrheal losses with 10 mL/kg of oral rehydration solution for each watery stool 5.
Critical Clinical Pitfall
The temptation to add alkali (sodium acetate, sodium bicarbonate) to maintenance fluids is unnecessary and potentially harmful—it adds sodium load without addressing the underlying problem, which is volume depletion 1.
The bicarbonate of 11 reflects both volume depletion and ongoing bicarbonate losses in stool; aggressive fluid resuscitation addresses both issues simultaneously 1, 2.