What is the treatment for acidosis?

Treatment of Acidosis

The primary treatment for acidosis is addressing the underlying cause: restore spontaneous circulation in cardiac arrest, administer insulin and fluids for diabetic ketoacidosis, provide ventilatory support for respiratory acidosis, and use oral sodium bicarbonate for chronic kidney disease-associated acidosis when serum bicarbonate is consistently <18 mmol/L. 1, 2

Metabolic Acidosis Treatment

Acute Metabolic Acidosis

Diabetic Ketoacidosis (DKA)

• Insulin therapy, fluid resuscitation, and electrolyte replacement are the cornerstones of DKA treatment—not bicarbonate. 1, 2
• Continuous intravenous insulin is the standard of care for critically ill and mentally obtunded patients with DKA. 1
• Restoration of circulatory volume and tissue perfusion is the primary goal. 1
• Bicarbonate administration has not been shown to improve resolution of acidosis or time to discharge in DKA and is generally not recommended. 3, 1, 2
• Youth with ketosis/ketoacidosis should receive subcutaneous or intravenous insulin to rapidly correct hyperglycemia and metabolic derangement, with metformin initiated once acidosis resolves. 3

Lactic Acidosis and Sepsis-Related Acidosis

• Focus on restoring tissue perfusion and treating the underlying condition (sepsis, shock). 2
• Do not use sodium bicarbonate to treat metabolic acidosis arising from tissue hypoperfusion in sepsis—instead, treat the underlying infection and restore tissue perfusion. 2

Cardiac Arrest

• The best method of reversing acidosis associated with cardiac arrest is to restore spontaneous circulation. 3
• Provided effective basic life support is performed, arterial blood-gas analysis shows neither rapid nor severe development of acidosis during cardiorespiratory arrest in previously healthy individuals. 3
• Sodium bicarbonate use should be limited to patients with severe acidosis (arterial pH <7.1 and base deficit <10) and to cardiac arrest occurring in special circumstances, such as hyperkalemia or tricyclic antidepressant overdose. 3
• There is no clinical evidence that any buffer is effective in increasing survival rates after human cardiac arrest. 3

Severe Metabolic Acidosis Requiring Bicarbonate

• Sodium bicarbonate is indicated for metabolic acidosis in severe renal disease, uncontrolled diabetes, circulatory insufficiency due to shock or severe dehydration, extracorporeal circulation, cardiac arrest, and severe primary lactic acidosis. 4
• Vigorous bicarbonate therapy is required when rapid increase in plasma total CO2 content is crucial. 4
• Intravenous sodium bicarbonate increases plasma bicarbonate, buffers excess hydrogen ion concentration, raises blood pH, and reverses clinical manifestations of acidosis. 4
• Treatment of severe metabolic acidosis (pH <7.2) requires sodium bicarbonate, but blood pH and gases should be monitored closely to avoid "overshoot" alkalosis. 5

Chronic Metabolic Acidosis

Chronic Kidney Disease (CKD)

• Treat CKD-associated acidosis when serum bicarbonate is consistently <18 mmol/L to prevent bone and muscle metabolism abnormalities. 1
• Maintain serum bicarbonate at or above 22 mmol/L. 1, 2
• Oral sodium bicarbonate 2-4 g/day (25-50 mEq/day) can effectively increase serum bicarbonate concentrations in CKD patients. 1, 2
• Correction of acidemia has been associated with increased serum albumin, decreased protein degradation rates, increased plasma concentrations of branched chain amino acids, and improved nutritional status. 1, 2
• Avoid citrate alkali salts in CKD patients exposed to aluminum salts as they may increase aluminum absorption. 1

Maintenance Dialysis Patients

• Maintain serum bicarbonate at or above 22 mmol/L. 1
• Use higher bicarbonate concentrations in dialysate (38 mmol/L). 2
• Monitor serum bicarbonate levels monthly. 1

Renal Tubular Acidosis

• In children with renal tubular acidosis, normalization of serum bicarbonate is important for normal growth parameters. 1
• Address the specific type of RTA with appropriate treatment. 2

Respiratory Acidosis Treatment

Acute Hypercapnic Respiratory Failure (AHRF)

• Initiate non-invasive ventilation (NIV) when pH <7.35 and pCO2 >6.5 kPa persist or develop despite optimal medical therapy. 3
• In extreme acidosis (pH <7.25), NIV should be initiated without waiting for chest X-ray. 3
• For most patients with acute exacerbation of COPD (AECOPD), initial management should be optimal medical therapy and targeting oxygen saturation of 88-92%. 3
• Optimal medical therapy, including controlled oxygen therapy, leads to resolution of respiratory acidosis in 20% of individuals with AECOPD. 3
• Severe acidosis alone does not preclude a trial of NIV in an appropriate area with ready access to staff who can perform safe endotracheal intubation. 3
• NIV should not delay escalation to invasive mechanical ventilation when this is more appropriate. 3

General Respiratory Acidosis Management

• Treatment requires identification and correction of the cause of alveolar hypoventilation. 6, 7
• May require invasive or noninvasive ventilatory support and specific medical therapies directed at the underlying pathophysiology. 6

Monitoring and Special Considerations

Laboratory Monitoring

• ABG measurement is needed prior to and following starting NIV. 3
• Monitor electrolytes, particularly potassium levels, as acidosis can cause hyperkalemia due to transcellular shift of potassium. 1, 5
• Plasma potassium should be monitored closely during treatment of acid-base disturbances. 5
• Improvement in physiological parameters, usually within 1-2 hours (particularly pH and respiratory rate), predicts successful outcome from NIV treatment. 3

Important Caveats

• Administration of bicarbonate solutions may worsen intracellular acidosis, reduce ionized calcium, and produce hyperosmolality. 1
• Treatment of all acid-base disorders must be aimed at diagnosis and correction of the underlying disease process. 5
• Specific treatment may be required when changes in pH are severe (pH <7.2 or pH >7.6). 5
• Worsening of physiological parameters, particularly pH and respiratory rate, is predictive of increased risk of death and/or requirement for intubation. 3