Approach Ali abd alrezaq

Aya abd alnasser

to acidosis Zainab muaid

sup//Prof Yusra AR Mahmood

Pediatrics department
2ND C.C.P
AlIraqia University
JULY,31TH
Oct/
Background
theaccumulationofacidandhydrogenionsord .
epletionofthealkalinereserve(bicarbonatecont
ent)inthebloodand
.bodytissues,resultinginadecreaseinpH
Acidosis occurs when your kidneys and lungs
.cant keep your bodys pH in balance
The pH of your blood should be around 7.4.
(7,35_7,45)
 types of Acidosis

Respiratory acidosis
occurs when too much CO2 builds up in the body. Normally the
lungs remove CO2 while you breathe. However, sometimes your
:body cant get rid of enough CO2. This may happen because of
chronic airway conditions, like asthma
injury to the chest
obesity, which can make breathing difficult
muscle weakness in the chest
deformed chest structure
Causes of Acidosis

Metabolic Acidosis
Metabolic acidosis starts in the kidneys instead of the lungs. It occurs when they cant
eliminate enough acid or when they get rid of too much base. There are three major
:forms of metabolic acidosis
{Renal failure[inability to excrete the dietary H +load

Diabetic acidosisoccurs in people with diabetes thats poorly controlled. If your

.body lacks enough insulin, ketones build up in your body and acidify your blood

Hyperchloremic acidosisresults from a loss of sodium bicarbonate. This base

helps to keep the blood neutral. Both diarrhea and vomiting can cause this type of
.acidosis

Lactic acidosisoccurs when theres too much lactic acid in your body. Many
things can cause a buildup of lactic acid. These include heart failure, cancer, seizures, e,
prolonged lack of oxygen, and low blood sugar. Even prolonged exercise can lead to lactic
.acid buildup
Others,toxification

Ingestions -Salicylates, methanol, ethylene

glycol,]iron,, sulfur,,, /metformin,and
hyperalimentation fluids
These all increase H ion
 History(digging)

Metabolic acidosis can result in a variety of nonspecific changes in

several organ systems, including, but not limited to, neurologic,
cardiovascular, pulmonary, gastrointestinal, and musculoskeletal
dysfunction. Symptoms are often specific to and a result of the
underlying etiology of the metabolic acidosis
:GI findings include the following

Nausea and vomiting

Abdominal pain

Diarrhea

!!!!
Polyphagia
 history

:Cardiovascular findings include the following

Palpitations
Chest pain
:Neurologic findings include the following
Headache
Visual changes
Mental confusion

:Musculoskeletal findings include the following
Generalized muscle weakness
Bone pain
 Physical signs

Cardiovascular

Severe acidemia (ie, pH < 7.10) can predispose a patient to

potentially fatal ventricular arrhythmias, and it can reduce cardiac
contractility and the inotropic response to catecholamines, resulting in
.hypotension and congestive heart failure
..
Pulmonary
Patients with acute metabolic acidosis demonstrate
.tachypnea and hyperpnea as prominent physical signs
Kussmaul respiration, an extremely intense respiratory
.effort, may be present
Hyperventilation, in the absence of obvious lung disease,
should alert the clinician to the possibility of an underlying
.metabolic acidosis
Neurologic
.Cranial nerve palsies may occur with ethylene glycol intoxication
.Retinal edema may be seen in methanol ingestions
Lethargy, stupor, and coma may occur in severe metabolic acidosis,
.particularly when it is associated with a toxic ingestion

Investigations
.Anarterial blood gas (ABG) measurementreveals the acidemia
Basic laboratory tests for a child with metabolic acidosis should include
measurements of electrolytes, RFT, and serum glucose levels, as
.well as a urinalysis
management

we usually need to know what is causing your acidosis to determine how to treat it.
However, some treatments can be used for any type of acidosis

Respiratory Acidosis
Treatments for this condition are usually designed to help your
lungs. example, you may be given drugs to dilate your airway.
You might also be given oxygen or a continuous positive airway
pressure (CPAP) device. The CPAP device can help you breathe if
.you have an obstructed airway or muscle weakness
Metabolic Acidosis
The specific types of metabolic acidosis each have their own
treatments. People with hyperchloremic acidosis may be given
oral sodium bicarbonate. Acidosis from kidney failure may be
treated with sodium citrate. Diabetics with ketoacidosis
receive IV fluids and insulin to balance out their pH. Lactic
acidosis treatment might include bicarbonate supplements, IV
fluids, oxygen, or, antibiotics, depending on the cause
 .Management

Biocarbonate therapy_hco3_1
In instances in which the serum bicarbonate level is only mildly to moderately depressed (>10-12
mEq/L) normally its(22_26 meq/l)., bicarbonate replacement may not be necessary. If the underlying
disease is treated appropriately, the kidneys are able to replenish bicarbonate stores within 3-4 days,
.unless significant renal dysfunction is present
Emergent bicarbonate therapy may be warranted in decompensated shock states in patients with a
pH of less than 7.1
The general recommendation is to replace only half of the total bicarbonate deficit during the first
.few hours of therapy

. 2

bicarbonate deficit can be calculated as follows:

(Desired Bicarbonate - Measured Bicarbonate) x Weight
(kg) x 0.6
Cardiac arrest////Initial: 1 mEq/kg/min given over 1-2 minutes
IV/IO(shoot)..then 0.5 mEq/kg IV q10min of arrest
Metabolic Acidosis (Non-Life-Threatening)
mEq/kg IV infusion over 4-8 hr 2-5

The initial therapeutic goal for patients with severe

acidemia is to raise above 7.1-7.2, a level at which
dysrhythmias become less likely and cardiac
contractility and responsiveness to catecholamines
will be restored
Bicarbonate vial nahco
 Notes on hco3 therapy

Do not overestimate or overcorrect the bicarbonate deficit. Rapid infusion of
bicarbonate for chronic conditions and overcorrection of the metabolic
acidosis can lead to complications such as tetany, seizures, and hypokalemia
by worsening the preexisting hypocalcemia and hypokalemia
newborns, frequent administration of hypertonic solutions, such as sodium
bicarbonate, have led to intracranial hemorrhage resulting from
hyperosmolality and resultant fluid shifts from the intracellular space
Rapid infusion of sodium bicarbonate to correct metabolic acidosis has led to
paradoxical CNS acidosis in several studies. The cause is believed to be
sodium bicarbonate dissociating into carbon dioxide and water; carbon
dioxide rapidly crosses the blood-brain barrier, but bicarbonate does not,
.leading to CNS acidosis
 Contraindication of bicarbonate

Hypersensitivity, metabolic or respiratory alkalosis, hypocalcemia,

excessive Cl- loss from vomiting or GI suctioning

Cautions
Avoid extravasation (may cause chemical cellulitis, tissue necrosis,
ulceration
 supportive
Thiamine_2

deficiency should be considered for patients with lactic acidosis and shock on long-
term total parenteral nutrition without multivitamins for 2 or more weeks. Thiamine
administration rapidly corrects the clinical symptomatology.The dosage forms include
a parenteral injection (100 mg/mL) and tablets

Tromethamine_3

is a buffer that can be( also called THAM ortris[hydroxymethyl]-aminomethane)

used to treat acidosis when concerns exist regarding carbon dioxide accumulation
from the metabolism of administered sodium bicarbonate. THAM increases serum
bicarbonate predictably>dose 1meq/kg
Interventional management

Hemodialysis
Hemodialysis is an option for correcting a severe metabolic acidosis with
renal failure or intoxication with methanol or ethylene glycol

Surgical care
Surgical care may be indicated based on the etiology of metabolic acidosis.
Tissue ischemia or necrosis from bowel obstruction or necrotizing
.enterocolitis, with or without peritonitis, may lead to metabolic acidosis
Especially in newborns with necrotizing enterocolitis, metabolic acidosis may
be the first laboratory abnormality associated with a surgical abdomen
 complication
Without prompt treatment, acidosis may lead to the following health
:complications
sizures

kidney stones

chronic kidney problems

kidney failure

bone disease
delayed growth Some people fully recover from acidosis. Other people have problems with
organ function, respiratory failure, and kidney failure. Severe acidosis can cause shock or even
.death
How well you recover from acidosis depends on its cause. Fast, proper treatment also
.strongly influences your recovery
 Mortality and
morbidity
Untreated severe metabolic acidosis may be associated with
life-threatening arrhythmias, myocardial depression, and
respiratory muscle fatigue but is not generally the ultimate
.cause of morbidity and mortality
Perinatal metabolic acidosis in very low birthweight infants is
associated with higher mortality and neurodevelopmental
impairment.[4]
No race predilection is noted in metabolic acidosis, and the
prevalence rates for the condition are equal in males and
.females
Metabolic acidosis can occur in any age group
 Prognosis
Patient outcome depends on the nature of the disease process that
led to metabolic acidosis. Children with an inherited metabolic
disease require long-term, specialized management and a special
.diet
Those with diabetic ketoacidosis need lifelong insulin
.administration and an appropriate diet
Patients who develop a metabolic acidosis secondary to a toxic
ingestion or poisoning have the potential to recover without long-
.standing consequences
References:

/http://emedicine.medscape.com_1

learn.pediatrice artticles_2

Pediatric Decision-Making Strategies_3

http://www.healthline.com/health/acidosis#Treatment6

Nelson Textbook of pediatrics

Thank you