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Reliable, easy-to-read patient information on common medical conditions — written in plain language, free of jargon, and grounded in current evidence. Browse the most frequent diagnoses, understand what they mean for everyday life, and learn which steps and questions help you have a focused conversation with your doctor.

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Metabolic acidosis resident survival guide

Introduction

Overview

Overview

Metabolic acidosis is a state in which the blood pH is low (less than 7.35) due to a decreased blood concentration of bicarbonate.

Causes

Causes

Life Threatening Causes

Common Causes

Normal Anion Gap Metabolic Acidosis

The mnemonic for the most common causes of a normal-anion gap metabolic acidosis is “DURHAM.”

High Anion Gap Metabolic Acidosis

The mnemonic “MUDPILES” is used to remember the common causes of a high anion gap.

Management

Management

Step 1

 
 
 
 
 
 
 
 
 
 
pH<7.35
And
[HCO3–]<24 meq/L
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Metabolic acidosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Calculate the anion gap (AG)

Na+ – Cl– – HCO3–
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low AG
AG<8
 
 
 
 
 
Normal AG
8<AG<16
 
 
 
 
 
 
High AG
AG>16
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check albumin

Correct the AG if albumin is low
For every decrease of 1 g/dl of albumin, AG is decreased by 2.5 meg/L
 
Check Ca2+, Mg2+, K+, immunoglobulins

High levels of these unmeasured cations decrease the AG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check urine AG
Na+ + K+ – Cl–
 
 
 
 
 
 
Check ΔAG/ΔHCO3–
 
 
R/O low Ca2+, Mg2+, K+
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative urine AG

GI causes
RTA type II
 
 
 
Positive urine AG

Renal failure
RTA type I
RTA type IV
 
ΔAG/ΔHCO3–<1

High AG metabolic acidosis combined with normal AG metabolic acidosis
 
1<ΔAG/ΔHCO3–<2

Pure high AG metabolic acidosis
 
ΔAG/ΔHCO3–>2

High AG metabolic acidosis combined with metabolic alkalosis

Step 2

Shown below is the algorithm summarizing the management of metabolic acidosis

 
 
 
 
 
 
 
 
History, symptoms and physical examination
Blood pH < 7.35
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical examination
Eyes
Extremities
Neurologic (cranial nerves)
 
 
 
 
Labs/EKG
Anion gap, Arterial blood gas analysis
Electrolytes (Na, K, Cl, HCO3)
CBC
Serum lactate, ketone
Urinalysis
Toxicological screening (salicylate, methanol, ethylene glycol)
EKG for arrhythmias
 
 
 
 
History
Arrhythmias
Kussmaul breathing
Headache, altered mental status
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Place patient on EKG monitor for arrhythmias, hyperkalemia
 
Replace electrolytes if there are losses
 
If DKA, IV Insulin, normal saline
Potassium and phosphate may be necessary
 
Send consult to nephrologist for dialysis for renal failure, poisoning
 
Toxicological consult
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IV bicarbonate if there is cardiac arrhythmias
50-100mmol while monitoring arterial blood gas readings
 
 
 
 
 
 
 
 
 
 
 
 
 
Detoxification agents/toxin antidotes
Fomepizole
Activated charcoal
Emesis
Folic acid for methanol overdose
Thiamine and pyridoxine for ethylene glycol overdose
Do’s

Do’s

  • Treatment of the underlying cause should be the primary therapeutic goal.
  • Bicarbonate should be given only when there is a severe case of acidosis with an arterial pH of less than or equal to 7.2
  • Patient should be placed on SaO2 and blood pressure/heart rate monitor
  • Consider intubation and ventilation for airway if the SaO2 level is deteriorating or there is a loss of consciousness
  • Consider doing catherization to monitor the urine output and obtaining urine for urinalysis
Dont’s

Dont’s

References

References

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ogheneochuko Ajari, MB.BS, MS [2]