Guideline sources The following summarized guidelines for the evaluation and management of metabolic acidosis are prepared by our editorial team based on guidelines from the French Society of Emergency Medicine (SFMU/SRLF 2019). 1 Guidelines 1. Diagnostic investigations Laboratory testing: Consider obtaining arterial blood gas measurement in patients with decreased plasma bicarbonate level in order to: eliminate respiratory alkalosis confirm the diagnosis of metabolic acidosis test for mixed acidosis. E Show 12 more 2. Respiratory support https://web.pathway.md/diseases/reckMz4Zxen0AV9rH 1/3 6/30/23, 1:02 AM Metabolic acidosis Pathway Mechanical ventilation: consider increasing respiratory frequency without inducing intrinsic PEEP, with a maximum of 35 cycles/min and/or a tidal volume up to 8 mL/kg of body mass, and by monitoring plateau pressure for compensating acidemia. E Show 2 more 3. Medical management Sodium bicarbonate: consider administering sodium bicarbonate to compensate for gastrointestinal or renal base loss in patients with poor clinical tolerance. E Show 4 more Insulin: consider administering insulin IV rather than SC in patients with diabetic ketoacidosis. C Show 3 more 4. Inpatient care Inpatient monitoring: Consider monitoring the increase in blood lactate levels in the first hours of management to assess the response to treatment. C Consider obtaining close monitoring in patients with diabetic ketoacidosis, ideally in an ICU setting. E 5. Therapeutic procedures Renal replacement therapy: consider performing RRT in patients with shock and/or acute renal insufficiency if the pH 7.15 in the absence of severe respiratory acidosis and despite appropriate treatment. E Show 3 more Studies 2018 BICAR-ICU In adult patients admitted to the ICU within 48 hours experiencing severe acidemia and a total Sequential Organ Failure Assessment score 4 or an arterial lactate concentration 2 mmol/L, bicarbonate was not superior to control with respect to death from any cause by day 28 and the presence of at least one organ failure at day 7. Samir Jaber et al. Lancet. 2018 Jul 7. References https://web.pathway.md/diseases/reckMz4Zxen0AV9rH 2/3 6/30/23, 1:02 AM Metabolic acidosis Pathway 1. Boris Jung, Mika l Martinez, Yann-Erick Claessens et al. Diagnosis and management of metabolic acidosis: guidelines from a French expert panel. Ann Intensive Care. 2019 Aug 15;9 1 92. Open 2. Samir Jaber, Catherine Paugam, Emmanuel Futier et al. Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit BICAR ICU a multicentre, open-label, randomised controlled, phase 3 trial. Lancet. 2018 Jul 7;392 10141 31 40. Open https://web.pathway.md/diseases/reckMz4Zxen0AV9rH 3/3