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Acidosis

Acidoses

Acidosis is the condition of having too much acid in the blood and other body fluids with two classifications – metabolic acidosis or respiratory acidosis.


Presentation

Metabolic acidosis
The signs will depend on the underlying cause. Usually there will be a rapid breathing (tachypnoea), lethargy and confusion with a headache. Severe disease can progress to shock or death. There is a fruity smell from the ketones of diabetic acidosis [6].

Respiratory acidosis:
Presenting signs can include lethargy or fatigue, shortness of breath, confusion and sleepiness [7].

Camping
  • Conversely, dibutyryl cAMP (100-500 μM) delayed apoptosis of neutrophils cultured at pH 7.4.[ncbi.nlm.nih.gov]
Kussmaul Respiration
  • ., dyspnea, marked Kussmaul respirations) These patients generally have severe metabolic acidosis with respiratory compensation. This creates two concerns: If the metabolic acidosis worsens, they may decompensate.[emcrit.org]
  • respiration E87.2 Lacticemia, excessive E87.2 Retention - see also Retained carbon dioxide E87.2 ICD-10-CM Codes Adjacent To E87.2 E85.82 Wild-type transthyretin-related (ATTR) amyloidosis E85.9 Amyloidosis, unspecified E86 Volume depletion E86.9 Volume[icd10data.com]
  • Kussmaul's respiration may be noted where there is deep, slowly rhythmic breathing that increases the minute tidal volume. Children with chronic metabolic acidosis may have growth restriction and show signs of rickets.[patient.info]
Tachypnea
  • Tachypnea in physiological response to metabolic acidosis can be an early sign. Gastrointestinal side effects are a common side effect with therapeutic metformin use in the absence of lactic acidosis.[calpoison.org]
  • Patients experience cardiopulmonary symptoms, including tachycardia, tachypnea and in severe cases, shock. Stage 3 is usually the late stage, occurs 24 hours after the ingestion.[renalandurologynews.com]
  • Signs and symptoms [ edit ] Symptoms and signs of early hypercapnia include flushed skin, full pulse, tachypnea, dyspnea, extrasystoles, muscle twitches, hand flaps ( asterixis ), reduced neural activity, and possibly raised blood pressure.[en.wikipedia.org]
Hyperpnea
  • The most characteristic sign is hyperpnea (long, deep breaths at a normal rate), reflecting a compensatory increase in alveolar ventilation; this hyperpnea is not accompanied by a feeling of dyspnea.[merckmanuals.com]
Vomiting
  • This is the exact opposite of what happens when a person vomits. Vomiting causes metabolic alkalosis because a lot of stomach acid is lost when someone vomits, and this leads to the reduction of acidity within the body.[study.com]
  • This is because the symptoms of gastritis – nausea, vomiting and reduced eating – make you think less insulin is needed. And insufficient amounts of insulin can quickly lead to diabetic acidosis.[netdoctor.co.uk]
  • […] acidosis More Definitions for acidosis ac·i·do·sis \ ˌas-ə-ˈdō-səs \ plural acidoses \ -ˌsēz \ Medical Definition of acidosis : an abnormal condition of reduced alkalinity of the blood and tissues that is marked by sickly sweet breath, headache, nausea and vomiting[merriam-webster.com]
  • People with metabolic acidosis often have nausea, vomiting, and fatigue and may breathe faster and deeper than normal. People with respiratory acidosis often have headache and confusion, and breathing may appear shallow, slow, or both.[msdmanuals.com]
Nausea
  • If you develop severe metabolic acidosis, you will likely experience drowsiness and extreme weakness, as well as increased nausea and confusion, Merck Manuals note.[livestrong.com]
  • […] about acidosis More Definitions for acidosis ac·i·do·sis \ ˌas-ə-ˈdō-səs \ plural acidoses \ -ˌsēz \ Medical Definition of acidosis : an abnormal condition of reduced alkalinity of the blood and tissues that is marked by sickly sweet breath, headache, nausea[merriam-webster.com]
  • People with metabolic acidosis often have nausea, vomiting, and fatigue and may breathe faster and deeper than normal. People with respiratory acidosis often have headache and confusion, and breathing may appear shallow, slow, or both.[msdmanuals.com]
Hypotension
  • Incidence of hypotension did not differ between groups (54.5% vs. 61.9%, p   .63).[ncbi.nlm.nih.gov]
  • This resulted in progressive fetal hypoxaemia, acidosis and hypotension. The important question is the threshold of metabolic acidosis beyond which fetal morbidity may occur.[dictionary.cambridge.org]
  • In more severe cases it can present with altered mental status, coma, hypotension, hypothermia and respiratory insufficiency.[calpoison.org]
  • Metabolic acidosis due to paraldehyde overdose is exceedingly rare Iron and isoniazid are just two of many drugs and toxins that cause hypotension and lactic acidosis (isoniazid can also generate a component of ketoacidosis).[emergencymedicinecases.com]
  • Some weeks or months (in one case) after starting this therapy they suddenly became critically ill with severe hypotension, renal failure and rapidly deteriorating neurological state.[acutecaretesting.org]
Tachycardia
  • Cardiac telemetry monitoring showed a narrow complex sinus tachycardia. Laboratory analysis of blood collected soon after arrival showed the following blood gas: pH 7.16, pCO2 30 mmHg and bicarbonate of 15.[calpoison.org]
  • Precautions Caution in hypertension, cardiovascular disease, congestive heart failure, hyperthyroidism, diabetes, and seizures; not recommended for breastfeeding mothers; adverse reactions include tachycardia, headache, nervousness, dizziness, tremor,[web.archive.org]
  • Patients experience cardiopulmonary symptoms, including tachycardia, tachypnea and in severe cases, shock. Stage 3 is usually the late stage, occurs 24 hours after the ingestion.[renalandurologynews.com]
Confusion
  • These include rapid breathing, lethargy, tiredness, headaches and confusion. Diagnosis: Clinical signs and history should allow the underlying identification.[symptoma.com]
  • If you develop severe metabolic acidosis, you will likely experience drowsiness and extreme weakness, as well as increased nausea and confusion, Merck Manuals note.[livestrong.com]
  • Confusion or lethargy may also occur. Severe metabolic acidosis can lead to shock or death.[nlm.nih.gov]
  • Symptoms Return to top Symptoms may include: Confusion Easy fatigue Lethargy Shortness of breath Sleepiness Exams and Tests Return to top A chest x-ray or CT scan is a helpful way of checking the lung's appearance without having to biopsy it.[web.archive.org]
Lethargy
  • These include rapid breathing, lethargy, tiredness, headaches and confusion. Diagnosis: Clinical signs and history should allow the underlying identification.[symptoma.com]
  • Confusion or lethargy may also occur. Severe metabolic acidosis can lead to shock or death.[nlm.nih.gov]
  • Symptoms Return to top Symptoms may include: Confusion Easy fatigue Lethargy Shortness of breath Sleepiness Exams and Tests Return to top A chest x-ray or CT scan is a helpful way of checking the lung's appearance without having to biopsy it.[web.archive.org]
  • Symptoms may include: Confusion Anxiety Easy fatigue Lethargy Shortness of breath Sleepiness Tremors (shaking) Warm and flushed skin Sweating The health care provider will perform a physical exam and ask about symptoms.[nlm.nih.gov]
Stupor
  • In respiratory acidosis, the earliest symptoms are Drowsiness may progress to stupor and coma as the oxygen in the blood becomes inadequate.[merckmanuals.com]
  • Examination Lethargy, stupor and progression to a state of coma may occur, particularly in cases of poisoning. An intoxicated-appearing patient who has no smell of alcoholic drink on their breath may have ingested ethylene glycol.[patient.info]
Altered Mental Status
  • In more severe cases it can present with altered mental status, coma, hypotension, hypothermia and respiratory insufficiency.[calpoison.org]
  • Symptoms Neurological symptoms associated with this syndrome typically present after the ingestion of enteral formula or food high in carbohydrates (either simple or complex) and include altered mental status, slurred speech, confusion, disorientation[oley.org]

Workup

A full history and a thorough clinical examination will allow a correct diagnosis.

Laboratory support will provide extra information with arterial blood gas analyses and electrolyte analysis with a basic metabolic panel. These will confirm the acidosis and identify whether it is metabolic or respiratory in origins [8].

Ketonuria
  • Caution if ketonuria or drug anions are in the urine as it would invalidate the calculation. Diarrhea : UAG is a negative value. Renal tubular acidosis : UAG is positive value. As an aid, UAG is neGUTive when associated with bowel causes.[pulmonologyadvisor.com]
Hypercapnia
  • Hypercapnia and respiratory acidosis ensue when impairment in ventilation occurs and the removal of carbon dioxide by the respiratory system is less than the production of carbon dioxide in the tissues.[emedicine.com]
  • Acidosis was more frequent in the midazolam group (63.6% vs. 28.6%, p   .03), as was hypercapnia (50% vs. 14.3%, p   .03) while occurrence of hypoxemia did not differ between groups (22.7 vs. 33.3%, p   .5).[ncbi.nlm.nih.gov]
  • Oxygen therapy should be used with caution because it may worsen hypercapnia in some situations.[web.archive.org]
  • Alveolar hypoventilation leads to an increased PaCO 2 (ie, hypercapnia). The increase in PaCO 2 , in turn, decreases the bicarbonate (HCO 3 – )/PaCO 2 ratio, thereby decreasing the pH.[emedicine.medscape.com]
Hypocapnia
  • It is completed within 5-10 min from onset of hypocapnia b.[slideshare.net]
  • Often these diseases stimulate ventilation and hypocapnia due to reflex receptors and hypoxia. Hypercapnia typically occurs late in the disease process with severe pulmonary disease or when respiratory muscles fatigue.[emedicine.com]
  • Lung diseases that primarily cause abnormality in alveolar gas exchange usually do not cause hypoventilation but tend to cause stimulation of ventilation and hypocapnia secondary to hypoxia.[en.wikipedia.org]

Treatment

The mainstay of treatment is the use of appropriate fluid therapy using either oral or intravenous routes.

Sodium acetate may be used specifically to neutralise the acids.

At the same time the underlying cause must be treated.

In the most severe cases, severe measures such as mechanical ventilation or liver transplantation may be indicated [9].

Prognosis

The prognosis is generally favourable if prompt treatment is initiated. However, complications depend on the underlying cause.

Etiology

Acidosis occurs when the pH (hydrogen ion concentration) of blood plasma falls below 7.35.

  1. Respiratory acidosis (also known as hypercapnic acidosis) is the result of too much carbon dioxide remaining in the body because inadequate amounts are being removed by breathing.
  2. Metabolic acidosis occurs when either too much acid is produced in the body or too little is removed by the kidneys [2].

Epidemiology

1. Respiratory acidosis can be caused by inadequate respiratory function for several underlying reasons -

2. Several different forms of metabolic acidosis can occur with several various types of underlying pathology:

Lactic acidosis occurs as a result of the build-up of lactic acid -

Diabetic acidosis (also known as diabetic ketoacidosis – DKA) occurs as a result of the accumulation of acidic ketone bodies during uncontrolled diabetes mellitus.

Hyperchloraemic acidosis occurs with the loss of sodium bicarbonate from the body, e.g. sever diarrhoea or vomiting.

Other reasons for metabolic acidosis include – [3]

Sex distribution
Age distribution

Pathophysiology

Metabolic acidosis can either be caused when there is inadequate removal of excessive metabolicacids by the kidneys or over-production of metabolic acids elsewhere in body by other disturbed systems. These latter include urea and creatinine as well as the metabolic residues of protein catabolism. Overproduction of lactic acid can occur with excessive exercise or as a result of hypoxia in tissues with poor blood perfusion or low blood oxygen levels [4].
Stimulation of chemoreceptors by the raised acid levels leads to increased alveolar ventilation and results in some compensation for metabolic acidosis by the lungs with increased carbon dioxide exhalation. This alters the body’s buffering system to further reduce the metabolic acidosis.

Respiratory acidosis is usually the result of ineffective breathing and to return this back to a normal condition it will usually be useful to reverse the acidosis. However, where there is severe disturbance, e.g. trauma or nerve paralyses, mechanical ventilation may be needed as well [5].

Prevention

Mechanisms for prevention depend on the underlying cause. Metabolic acidosis can be prevented by ensuring the proper management of the underlying causes, e.g hepatic, renal and diabetic disease as well as avoiding excessive exercise or dehydration [10].

Summary

Normally the kidneys and the lungs maintain the balance between acids and bases in the body as part of homoeostasis so that the level of acidity (pH) is maintained within a narrow range – about 7.4. When either the acids build up or the bicarbonate (base) is lost, acidosis develops [1].

Patient Information

Definition: Acidosis is a buildup of acids in the body so that the pH of the blood plasma falls below 7.35


Cause: There are two types of acidosis depending on the underlying cause.

1. Metabolic acidosis - in which the kidneys are unable to effectively remove the acids produced by the body’s metabolism or in which the body is over-producing certain acids so that normal mechanisms can no longer maintain the level of hydrogen ions within the normal range. Potential causes include uncontrolled diabetes, over-exercise, poor diet, dehydration, overuse of drugs, diseases of the kidney and liver.


2. Respiratory acidosis results from the inability of the lungs to effectively remove carbon dioxide from the body. Changes in the lung ventilation may be caused by such chronic diseases as asthma, chest deformities, cancer, trauma to the chest or altered nerve function.


Symptoms: The symptoms of acidosis are similar for both the respiratory and metabolic forms. These include rapid breathing, lethargy, tiredness, headaches and confusion.

Diagnosis: Clinical signs and history should allow the underlying identification. Analysis of blood samples supported by a basic metabolic panel will provide an electrolyte analysis, while arterial blood gas analysis will conform the acidosis and identify whether this is metabolic or respiratory in origins.

Treatment: Fluid therapy with appropriate solutions, either oral or intravenous, will be used to correct the acidosis. Sometimes sodium acetate is used separately to neutralize the acids. Correcting the underlying problem is also important. Sometime mechanical ventilation is needed to correct severe respiratory acidosis.

Prevention: Correct management of the disease is critical to prevention its further development. Examples include controlling diabetes and avoiding excessive exercise or severe weather that might lead to dehydration.

References

Article

  1. Winter SD, Pearson JR, Gabow PA, et al. The fall of the serum anion gap. Arch Intern Med 1990; 150:311.
  2. Morimatsu H, Toda Y, Egi M, et al. Acid-base variables in patients with acute kidney injury requiring peritoneal dialysis in the pediatric cardiac care unit. J Anesth. 2009;23(3):334-40.
  3. Fernandez PC, Cohen RM, Feldman GM. The concept of bicarbonate distribution space: the crucial role of body buffers. Kidney Int 1989; 36:747.
  4. Pereira PC, Miranda DM, Oliveira EA, Silva AC. Molecular pathophysiology of renal tubular acidosis. Curr Genomics. Mar 2009;10(1):51-9
  5. Corey HE. Stewart and beyond: new models of acid-base balance. Kidney Int 2003; 64:777.
  6. Kraut JA, Kurtz I. Metabolic acidosis of CKD: diagnosis, clinical characteristics, and treatment. Am J Kidney Dis 2005; 45:978.
  7. Ehrsam RE, Heigenhauser GJ, Jones NL. Effect of respiratory acidosis on metabolism in exercise. J Appl Physiol. Jul 1982;53(1):63-9.
  8. Wiseman AC, Linas S. Disorders of potassium and acid-base balance. Am J Kidney Dis. May 2005;45(5):941-9
  9. Pierce NF, Fedson DS, Brigham KL, et al. The ventilatory response to acute base deficit in humans. Time course during development and correction of metabolic acidosis. Ann Intern Med 1970; 72:633.
  10. Adrogué HJ, Eknoyan G, Suki WK. Diabetic ketoacidosis: role of the kidney in the acid-base homeostasis re-evaluated. Kidney Int 1984; 25:591.

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Last updated: 2019-07-11 22:43