Clinical and Experimental Nephrology

, Volume 10, Issue 2, pp 111–117 | Cite as

Use of base in the treatment of acute severe organic acidosis by nephrologists and critical care physicians: results of an online survey

ORIGINAL ARTICLE

Abstract

Background

Acute severe metabolic acidosis associated with lactic acidosis or ketoacidosis can have severe detrimental effects on organ function, and might contribute to mortality. A general consensus exists that elimination of the cause of the acidosis is essential for treatment, but there is controversy concerning the use of base for the treatment of these disorders. Some physicians advocate administration of base when the acidosis is severe to prevent a decrease in cardiac output, whereas others oppose administration of base even when the acidosis is severe given the potential compromise of cardiac function. Nephrologists and critical care specialists are often the physicians developing recommendations for the treatment of severe acid-base disorders.

Methods

A short online survey of 20 questions was developed to assess the approach to the treatment of acute metabolic acidosis of program directors of fellowship programs and experts from the specialties of critical care and nephrology.

Results

Although there was variability among individual physicians from both specialties, a larger percentage of nephrologists than critical care physicians queried recommended administration of base for the treatment of lactic acidosis (86% vs 67%) and ketoacidosis (60% vs 28%). Also, critical care physicians in general used a lower level of blood pH when deciding when to initiate treatment. Of the physicians who gave base, most utilized sodium bicarbonate as the form of base given.

Conclusions

The results of this survey indicate that the decisions whether to use base for the treatment of acute severe metabolic acidosis, and under which circumstances, vary among physicians, and indicate the need for further studies to develop evidence-based guidelines for therapy.

Key words

Lactic acidosis Ketoacidosis Bicarbonate 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Kreisberg, RA 1980Lactate homeostasis and lactic acidosisAnn Intern Med9222737PubMedGoogle Scholar
  2. 2.
    Kraut, JA, Kurtz, I 2001Use of base in the treatment of severe acidemic statesAm J Kidney Dis3870327PubMedGoogle Scholar
  3. 3.
    Stacpoole, PW, Wright, EC, Baumgartner, TG, Bersin, RM, Buchalter, S, Curry, SH,  et al. 1994Natural history and course of acquired lactic acidosis in adultsAm J Med974754PubMedCrossRefGoogle Scholar
  4. 4.
    Lorkovic, H 1966Influence of changes in pH on the mechanical activity of cardiac muscleCirc Res1971120PubMedGoogle Scholar
  5. 5.
    Watters, TA, Wendland, MF, Parmley, WW, James, TL, Botvinick, EH, Wu, ST,  et al. 1987Factors influencing myocardial response to metabolic acidosis in isolated rat heartsAm J Physiol253H126170PubMedGoogle Scholar
  6. 6.
    Narins, RG, Cohen, JJ 1987Bicarbonate therapy for organic acidosis: the case for its continued useAnn Intern Med1066158PubMedGoogle Scholar
  7. 7.
    Adrogue, HJ, Madias, NE 1998Management of life-threatening acid-base disordersN Engl J Med33810710PubMedCrossRefGoogle Scholar
  8. 8.
    Stacpoole, PW 1986Lactic acidosis: the case against bicarbonate therapyAnn Int Med1052769PubMedGoogle Scholar
  9. 9.
    Gamba, G, Oseguera, J, Castrejon, M, Gomez-Perez, FJ 1991Bicarbonate therapy in severe diabetic ketoacidosis. A double blind, randomized placebo controlled studyReva Invest Clin432348Google Scholar
  10. 10.
    Gabow, PA, Kaehny, WD, Fennessey, PV, Goodman, SI, Gross, PA, Schrier, RW 1980Diagnostic importance of increased serum anion gapN Engl J Med3038548PubMedCrossRefGoogle Scholar
  11. 11.
    Graf, H, Leach, W, Arieff, AI 1985Evidence for a detrimental effect of bicarbonate therapy in hypoxic lactic acidosisScience2277546PubMedGoogle Scholar
  12. 12.
    Forsythe, S, Schmidt, GA 2000Sodium bicarbonate for the treatment of lactic acidosisChest1172607PubMedCrossRefGoogle Scholar
  13. 13.
    Garella, S, Dana, CL, Chazan, JA 1973Severity of metabolic acidosis as a determinant of bicarbonate requirementsN Engl J Med2891216PubMedCrossRefGoogle Scholar
  14. 14.
    Adroque, HJ, Madias, NM 1997Aiding fluid prescription for the dysnatremiasIntensive Care Med2330916CrossRefGoogle Scholar
  15. 15.
    Shapiro, JI 1997Pathogenesis of cardiac dysfunction during metabolic acidosis: therapeutic implicationsKidney Int61S4751Google Scholar
  16. 16.
    Graf, H, Leach, W, Arieff, AI 1985Metabolic effects of sodium bicarbonate in hypoxic lactic acidosis in dogsAm J Physiol Renal Fluid Electrolyte Physiol249F6305Google Scholar
  17. 17.
    Avkiran, M, Ibuki, C 1992Reperfusion-induced arrhythmias: a role for washout of extracellular protons?Circ Res71142940PubMedGoogle Scholar
  18. 18.
    Levitsky, J, Gurell, D, Frishman, WH 1998Sodium ion/hydrogen ion exchange inhibition: a new pharmacologic approach to myocardial ischemia and reperfusion injuryJ Clin Pharmacol3888797PubMedGoogle Scholar
  19. 19.
    Gores, GJ, Nieminen, AL, Wray, BW, Herman, B, Intracellular, Lemasters JJ. 1989pH during chemic hypoxia in cultured rat hepatocytesJ Clin Invest8338696PubMedCrossRefGoogle Scholar
  20. 20.
    Nahas, GG, Sutin, KM, Fermon, C 1998Guidelines for the treatment of acidaemia with THAMDrugs551914PubMedCrossRefGoogle Scholar
  21. 21.
    Weber, T, Tschernich, H, Sitzwohl, C, Ullrich, R, Germann, P, Zimpfer, M,  et al. 2000Tromethamine buffer modifies the depressant effect of permissive hypercapnia on myocardial contractility in patient with acute respiratory distress syndromeAm J Resp Crit Care Med16213615PubMedGoogle Scholar
  22. 22.
    Ayus JC, Krothapalli RK. Effect of bicarbonate administration on cardiac function. 1989;87:5–6Google Scholar
  23. 23.
    Morris, LR, Murphy, MB, Kitabchi, AE 1986Bicarbonate therapy in severe diabetic ketoacidosisAnn Intern Med10583640PubMedGoogle Scholar
  24. 24.
    Okuda, Y, Adrogue, HJ, Field, JB, Nohara, H, Yamashita, K 2000Conterproductive effects of sodium bicarbonate in diabetic ketoacidosisJ Clin Endocrinol Metab813149CrossRefGoogle Scholar
  25. 25.
    Viallon, A, Zeni, R, Lafond, P, Venet, C, Tardy, B, Page, Y,  et al. 1999Does bicarbonate therapy improve the management of severe diabetic ketoacidosis?Crit Care Med2726903PubMedCrossRefGoogle Scholar
  26. 26.
    Glaser, N, Barnett, P, McCaslin, I, Nelson, D, Trainor, J, Louie, J,  et al. 2001Risk factors for cerebral edema in children with diabetic ketoacidosisN Engl J Med3442649PubMedCrossRefGoogle Scholar
  27. 27.
    Cooper, DJ, Walley, KR, Wiggs, BR, Russell, JA 1990Bicarbonate does not improve hemodynamics in critically ill patients who have lactic acidosisAnn Intern Med1124928PubMedGoogle Scholar
  28. 28.
    Mathieu, D, Neviere, R, Billard, V, Fleyfel, M, Wattel, F 1991Effects of bicarbonate therapy on hemodynamics and tissue oxygenation in patients with lactic acidosis: a prospective, controlled clinical studyCrit Care Med1913526PubMedGoogle Scholar

Copyright information

© Japanese Society of Nephrology 2006

Authors and Affiliations

  1. 1.Medical and Research Services VHAGLA Healthcare SystemDivision of Nephrology VHAGLA Healthcare System and David Geffen School of MedicineLos AngelesUSA
  2. 2.Division of NephrologyUCLA Center for Health Sciences and David Geffen School of MedicineLos AngelesUSA

Personalised recommendations