Metabolic alkalosis

Acute toxicity from baking soda ingestion

Sodium bicarbonate is an extremely well-known agent that historically has been used for a variety of medical conditions. Despite the widespread use of oral bicarbonate, little documented toxicity has occurred, and the emergency medicine literature contains no reports of toxicity caused by the ingestion of baking soda. Risks of acute and chronic oral bicarbonate ingestion include metabolic alkalosis, hypernatremia, hypertension, gastric rupture, hyporeninemia, hypokalemia, hypochloremia, intravascular volume depletion, and urinary alkalinization. Abrupt cessation of chronic excessive bicarbonate ingestion may result in hyperkalemia, hypoaldosteronism, volume contraction, and disruption of calcium and phosphorus metabolism. The case of a patient with three hospital admissions in 4 months, all the result of excessive oral intake of bicarbonate for symptomatic relief of dyspepsia is reported. Evaluation and treatment of patients with acute bicarbonate ingestion is discussed.

Fluid and electrolyte balance in critical patients

Recognition and appropriate management of fluid and electrolyte disorders in critical patients is extremely important. In many cases, these secondary problems are more complicated and more serious than the initiating disease process. A severely ill diabetic patient, for example, is more likely to die from dehydration, hyperosmolality, metabolic acidosis, hypokalemia or hypophosphatemia than from hyperglycemia or lack of insulin therapy. Proper fluid therapy and treatment of electrolyte abnormalities make a major difference in the survival rate of critically ill animals.

Hydrochloric acid for treating metabolic alkalosis

Six patients with severe metabolic alkalosis were treated with intravenous hydrochloric acid (HCl) infusion. HCl was given through a central venous catheter, at a concentration of 0.1 mEq per ml. At least two of the following criteria were considered for initiation of the therapy: An arterial pH of greater than 7.45, a base excess (BE) of greater than +7 mmol/L, a PaCO2 of greater than 50 mmHg. The HCl amount was calculated using the BE formula, however, two thirds was infused for avoiding excessive acid loading. Patients were monitored by the blood gases, serum electrolytes, hemoglobin, hematocrit, bilirubin determinations and blood smear findings. While a significant decrease was noticed in pH and BE values, moderate changes were detected in PaCO2 due to different ventilatory status of the cases. All laboratory test results remained within normal limits and no complication was encountered. The advantage of the therapy is that less volume is needed for the correction of alkalosis, particularly in the cases requiring fluid restriction. HCl therapy, moreover, is a safe and time-saving method because of having rapid response to the treatment in the critically ill surgical patients.

Drug-induced metabolic disorders and parenteral nutrition in the intensive care unit: a pharmaceutical and metabolic perspective

Since its inception, the field of parenteral nutrition has continued to evolve requiring the expertise of several health care disciplines. This feature has made nutrition support unique among clinical subspecialties. As a member of this team, the pharmacist plays a critical role in the provision of sterile admixtures, compatible nutritional formulations, and cost-effective, therapeutically equivalent strategies. The pharmacist has become more involved in the clinical care of the patient, with particular emphasis on the development of drug-induced metabolic disorders. The multitude of drugs prescribed to hospitalized patients increases the potential for serious metabolic disturbances. This is especially true in the critical care setting where sudden changes in metabolism (e.g., acid-base homeostasis, fluid and electrolyte balance) may result in profoundly negative effects. The critical care setting also represents the most sensitive period of hospitalization where even subtle changes in metabolic homeostasis may assume major clinical significance. Early recognition of offending agents and the institution of appropriate intervention may avert serious iatrogenic diseases. The nutrition support team is in a unique position to address many such disorders through selective manipulation of the various components in the parenteral nutrient admixture. The ability of the pharmacist to recognize the development of drug-induced metabolic disorders lends further support for clinical pharmacy in nutrition support services.

Severe metabolic alkalosis in the emergency department

A case of severe metabolic alkalosis (MA) resulting from ingestion of baking soda (sodium bicarbonate) is presented. On admission to the emergency department, the patient was alert and stable with an initial examination that was remarkable only for carpopedal spasm. Shortly thereafter, the patient had a sudden, unexpected cardiopulmonary arrest. Following resuscitation, without administration of sodium bicarbonate, the arterial blood gas revealed a pH of 7.73, pO2 of 51 mm Hg, and pCO2 of 52 mm Hg. After admission to the intensive care unit, the patient's MA was corrected using IV 0.25 N hydrochloric acid. The patient remained comatose as a result of severe anoxic encephalopathy and died two weeks after admission. We believe this is the first reported case of severe MA resulting in sudden cardiopulmonary arrest in a previously ambulatory patient.

Disturbances in acid-base metabolism. Recognition in the office setting

Determination of the appropriateness of the compensatory response is essential in evaluation of any acid-base disturbance. Adequate compensation supports the presence of a single acid-base event. Inadequate compensation may indicate that a second primary acid-base event is present or, in some circumstances, that time has been inadequate for maximal physiologic compensation. When acid-base disturbances are mixed, treatment of one disorder may unmask the full pH-altering potential of the second disorder. Close monitoring of patients at risk for the development of acid-base disorders permits detection of problems at a time when intervention may prevent serious complications. Relatively inexpensive and easy-to-use chemical analytic systems to assist early diagnosis are now present in many office-based laboratories.

Acid-base disturbances in gastrointestinal disease

Gastrointestinal disorders are associated with severe and often complex acid-base disturbances. We review the most important types of metabolic alkalosis and metabolic acidosis associated with gastrointestinal disorders, excluding liver disease. Special emphasis is placed on pathophysiologic mechanisms. This information may help the clinician understand the generation and maintenance of these disorders and to plan an effective therapeutic approach.

A key to the literature of total parenteral nutrition: update 1987

This comprehensive bibliography is intended to enhance the education of the practitioner, student, and academician in the area of parenteral nutrition. This bibliography is not all-inclusive but serves as an update from the original published in 1983. Of particular note in this work is the addition of topics that reflect a growing interest in medical specialties with regard to patient nutritional status and support.

Metabolic alkalosis following administration of an organophosphorus compound, O,S,S-trimethyl phosphorodithioate

The oral administration of a single dose of O,S,S-trimethyl phosphorodithioate (OSSMe) to rats was found to result, 24 hours after treatment, in a dose-related metabolic alkalosis. Non-invasive indices of kidney damage revealed that during the first 4 hours after OSSMe administration there was a fourfold increase in urine flow with increases in albumin, beta 2-microglobulin and N-acetyl-glucosaminidase excretion. These results suggest that OSSMe-induced metabolic alkalosis may result from early renal functional disturbances.

Cerebral dysfunction following infantile dietary chloride deficiency

Twenty-two children who were chloride-depleted in infancy due to a chloride-deficient diet and who had resultant hypochloremic alkalosis were analyzed in regard to their signs and symptoms, metabolic studies, and growth parameters. Deceleration of weight, linear growth, and head growth occurred in most, and persistent growth failure occurred in some. The majority had cognitive deficits at follow-up. Comparison with growth parameters in a chronically malnourished group of children who had a variety of disorders revealed a similar degree of deceleration of weight (p = 0.50) and height (p = 0.70), but more severe deceleration of head growth (p = 0.01). Comparison with follow-up cognitive deficits reported in the United States medical literature in children with similar severity of nutritional deprivation indicates that the chloride-depleted infants had more frequent and more severe cognitive deficits (p = 0.09). Cognitive deficits have been documented in U. S. children who are nutritionally deprived only when disorders causing concomitant chloride depletion are responsible for the malnutrition.

Ascites, renal abnormalities, and electrolyte and acid-base disorders associated with liver disease

Ascites and renal dysfunction are often associated with decreased liver function and reflect the complex abnormalities of water, protein, electrolyte, and acid-base metabolism that may complicate severe liver disease. This article discusses the pathophysiology and management of ascites, polydipsia and polyuria, decreased renal function, and acid-base and electrolyte alterations that can complicate liver disease.