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Acid–Base Balance in the Poisoned Patient

  • Stephen W. Borron
Reference work entry

Abstract

Acid-base disorders are a major source of morbidity and mortality among patients in the intensive care unit (ICU). An observational cohort study of 9,799 ICU patients found that nearly two thirds of critically ill patients suffered from acute Metabolic Acidosis. Mortality among those with metabolic acidosis was 45% compared with 25% for those without it. For those with lactic acidosis, the mortality rate was 56% [1]. It is difficult to directly extrapolate these findings to poisoned patients who generally have a significantly lower mortality rate than the average ICU patient. We do know, however, from studies of poisonings with specific substances, such as metformin, ethylene glycol, and methanol, that the presence of severe metabolic acidosis is associated with a relatively poor prognosis [2]. A review of 22 cases of metformin overdose revealed a median pH nadir of 7.30 and median plasma lactate of 10.8 mmol/L among survivors compared with pH 6.71 and median plasma lactate of 35.0 mmol/L among non-survivors [2]. Among 18 ethylene glycol poisoned patients, non-survivors had a mean admission pH of 7.05, compared with 7.31 in survivors [3]. No patient with a pH less than 7.10 survived. Not surprisingly, most of the non-survivors presented to the hospital late after ingestion (from 6 h to > 24 h). In a review of one-time methanol exposures with known time of ingestion, 22 patients presented for care <6 h after ingestion and had an early methanol level. Sixteen of these were acidotic on arrival [4]. Blood methanol concentrations ranged from 10 to 570 mg/dL (3–178 mmol/L), and initial arterial pH ranged from 6.90 to 7.42. All underwent treatment with alcohol dehydrogenase inhibitors (with or without hemodialysis). One patient with pH 6.99 died. Three patients with pH ranging from 7.26 to 7.32 suffered optic neuropathies but survived. One patient with pH 6.90 was described as “alive” on discharge, with the remaining 11 (pH range 7.09–7.42) noted as having a full recovery. In summary, it appears that severe metabolic acidosis is associated with a poor prognosis in representative poisonings and that time of presentation plays a significant role in outcome. A larger study of the prognostic value of acid–base disturbances in poisoning in general among ICU patients would be edifying.

Keywords

Anion gap Acidosis Strong ion gap Respiratory alkalosis Salicylates Metabolic alkalosis Ethylene glycol 

Notes

Acknowledgment

This chapter is dedicated to the memory of Professor Chantal Bismuth, whose contributions to medical toxicology are innumerable and lasting. With her sharply analytical mind, incisive wit, and charming smile, she mentored hundreds of toxicologists-in-training, challenged the status quo, and brought focus to many nebulous concepts in toxicology. She will be missed.

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© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Medical ToxicologyTexas Tech UniversityEl PasoUSA

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