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Acidosis: Quick Steps to Evaluate, Protect and Intervene
Barbara McLean, MN, RN, CCRN, CCNS, CRNP, FCCM; bamclean@mindspring.com
Upon completion of this course, the participant will be able to:
1. Identify the complications that occur with metabolic acidosis;
2. Define the indicators of metabolic acidosis; and
3. Relate basic physiology to anion gap and potassium.
Metabolic Acidosis Complications A. When the patient has refractory hypotension 1. Consider the effects of hydrogen 2. Evaluate serum potassium 3. Determine the effects of vasopressor therapies 1. Cellular protection 2. Ion shifts 3. Loss of sympathetic tone 1. Treat the problem not the symptom 2. Neutralize the pH 3. Utilize agents that bypass sympathetic receptors D. Case study—12-year-old diabetic presents with Kussmaul breathing 1. pH: 7.05 2. pCO2: 12 mm Hg 3. pO2: 108 mm Hg 4. HCO3: 5 mEq/L 5. BE: -30 mEQ/L E. Case study—seven year-old post op presenting with chills, fever and hypotension 1. pH: 7.25 2. pCO2: 32 mm Hg 3. pO2: 55 mm Hg 4. HCO3: 10 mEq/L 5. BE: -15 mEQ/L The Indicators of Metabolic Acidosis: Simple to Sublime A. Simple predictors that require further evaluation 1. Persistent rapid respiratory rate 2. Persistent tachycardia 3. Perceived prodrome 4. Urinary output (U/O) less than 1.0 mL/kg 1. Anion gap 2. Ketoacid 3. Lactic acid 4. Central venous oxygen saturation 5. Skeletal muscle tissue oxygenation 6. End tidal carbon dioxide Basic Physiology to Anion Gap and Potassium A. When there is an increase in unmeasured ions, there will be a gap between the positive and negative measure. 1. A gap of greater than 20 implies a metabolic increase in acid production 2. Lactic acid and ketoacid donate H+ 3. Hydrogen binds to HCO3 and/or Chloride (CI) changing the charge; HCO3 and/or CI decreases. 4. The gap between positive and negative gets wide B. Ionic shift: potassium for hydrogen C. Strong ion dissociation D. Components if strong ion dissociation E. Cases
Resources
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·Finkle SN. Should dialysis be offered in all cases of metformin-associated lactic acidosis?. Crit Care.
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Casaletto JJ. Differential diagnosis of metabolic acidosis. Emerg Med Clin North Am. 2005;23:771–787.
Dell'aglio DM, Perino LJ, Kazzi Z, Abramson J, Schwartz MD, Morgan BW. Acute Metformin Overdose:
Examining Serum pH, Lactate Level, and Metformin Concentrations in Survivors Versus Nonsurvivors: A
Systematic Review of the Literature. Ann Emerg Med. Jun 24 2009;
Edwards SL. Pathophysiology of acid-base balance: the theory practice relationship. Intensive Crit Care Nurs.
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outcome evaluation of critically ill patients. Crit Care. Feb 10 2006;10(1):R22.
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massive overdoses of metformin. Semin Dial. Jan-Feb 2006;19(1):80-3.
JL. Acid-base disorders. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen's Emergency Medicine:
Concepts and Clinical Practice. 7th ed. Collings Philadelphia, Pa:Mosby Elsevier;2009:chap 122.
Oh MS. Evaluation of renal function, water, electrolytes and acid-base balance. In: McPherson RA, Pincus MR, eds. Henry's Clinical Diagnosis and Management of Laboratory Methods. 21st ed. Philadelphia, Pa: Saunders Elsevier; 2006: chap 14. Ruholl L. Arterial blood gas: analysis and nursing response. Medsurg Nurs. 2006;15:343–351. Reddy P, Mooradian AD. Clinical utility of anion gap in deciphering acid-base disorders. Int J Clin Pract. Oct 2009;63(10):1516-2 Salpeter SR, Greyber E, Pasternak GA, Salpeter Posthumous EE. Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus. Cochrane Database Syst Rev. Jan 20 2010;CD002967. Seifter JL. Acid-base disorders. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 119.

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