Most cases of metabolic acidosis present with non-specific signs and symptoms. These symptomatology and signs are most commonly seen among patients with established metabolic acidosis:

• Hyperventilation: The respiratory centers are stimulated to cause hyperventilation to help eliminate carbon dioxide from the blood during acidotic states. 
• Dyspnea: Breathing will be too fast and shallow impairing adequate oxygen exchange in the lungs.
• Chest pain: The acidic plasma triggers the release of some cytokines that may cause angina and temporary coronary vasospasm.
• Palpitation: The compensatory tachycardia will be felt as palpitation.
• Neurologic signs: Headache and confusion are common findings when the cerebrospinal fluid becomes acidic.
• Fatigue and weakness: Sodium channels are impaired during metabolic acidosis causing an essential hyponatremia in the extracellular space lowering the action potential in muscles.
• Nausea and vomiting: The toxic state of metabolic acidosis is exemplified as nausea and vomiting among children.
• Bone pains: The acidotic state causes vasospasm of the smaller arterioles that supply the bones presenting as sharp bone pains. Chronic calcium depletion with the acidemic state can also cause untimely osteoporosis among patients. 

• Kussmaul Respiration

  Kussmaul’s respirations B. Glucose 110 C. Hypoventilation D. Neuro-excitability The answer is A: Kussmaul’s respirations 10. A patient has the following arterial blood gases: PaCO2 33, HCO3 15, pH 7.23. Which condition below is presenting? A. [registerednursern.com]

  Infants will try to correct metabolic acidosis by a reflex respiratory alkalosis using hyperventilation and Kussmaul respirations. [mhmedical.com]

  EFFECTS Respiratory Effects hyperventilation (Kussmaul respirations) – this is the compensatory response shift of oxyhaemoglobin dissociation curve (ODC) to the right – due to the acidosis occurs rapidly decreased 2,3 DPG levels in red cells (shifting [litfl.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

  During the initial examination by the physician at our hospital, the patient presented with tachypnea, a precordinal burning sensation, nausea and metabolic acidosis. [ncbi.nlm.nih.gov]

  The resulting tachypnea and hyperpnea reduces the PaCO 2 in an attempt to increase the pH back toward normal. [emedicine.com]

  Hyperventilation (tachypnea) B. Hypoventilation (bradypnea) C. Increased potassium level (hyperkalemia) D. Constipation 5. What of the following is NOT a cause of metabolic alkalosis? * A. Hyperaldosteronism B. Usage of Diamox C. [registerednursern.com]

  Tachypnea and hyperventilation worsened during the ensuing 12 h. Blood gas analysis showed severe metabolic acidosis resulting in hypocapnia and a normal pH ( table 1 ). [anesthesiology.pubs.asahq.org]

  Tachycardia, tachypnea (with severe lactic acidosis), hypotension with symptoms similar to septic shock. Specific laboratory tests are to help identify the severity and presence of multiorgan involvement. [clinicaladvisor.com]

• Hyperpnea

  The resulting tachypnea and hyperpnea reduces the PaCO 2 in an attempt to increase the pH back toward normal. [emedicine.com]

  Symptoms and signs in severe cases include nausea and vomiting, lethargy, and hyperpnea. Diagnosis is clinical and with ABG and serum electrolyte measurement. The cause is treated; IV sodium bicarbonate may be indicated when pH is very low. [msdmanuals.com]

  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]

• Abnormal Breathing

  Other symptoms for lactic acidosis include: Nausea Vomiting Abdominal pain Lethargy Abnormal breathing Low blood pressure Irregular heart rhythm Causes of Lactic Acidosis Lactic Acidosis is caused if a person reaches the anaerobic threshold or lactate [acidalkalinediet.net]

• Dyspnea at Rest

  The current report describes the case of a 49-year-old African American woman who presented with severe pleuritic chest pain and dyspnea at rest. The patient had a history of alcohol-induced chronic pancreatitis. [ncbi.nlm.nih.gov]

• Vomiting

  Laboratory examinations reveal the presence of significant metabolic alkalosis despite the severe vomiting of the patient. Hypochloremic alkalosis would be expected to be present in this patient. [ncbi.nlm.nih.gov]

  Nausea and vomiting: The toxic state of metabolic acidosis is exemplified as nausea and vomiting among children. Bone pains: The acidotic state causes vasospasm of the smaller arterioles that supply the bones presenting as sharp bone pains. [symptoma.com]

• Nausea

  However, eight days after admission, he again reported nausea, a venous blood gas revealed metabolic acidosis with a normal anion gap. [ncbi.nlm.nih.gov]

  Nausea and vomiting: The toxic state of metabolic acidosis is exemplified as nausea and vomiting among children. Bone pains: The acidotic state causes vasospasm of the smaller arterioles that supply the bones presenting as sharp bone pains. [symptoma.com]

• Hypotension

  However, a change in consciousness and hypotension subsequently developed 6h later, combined with severe metabolic acidosis (pH7.16), high anion gap (25.5), and high osmolal gap (83). A presumed diagnosis of methanol intoxication was suspected. [ncbi.nlm.nih.gov]

  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]

  Also, with acidemia, cardiovascular response to endogenous and exogenous catecholamines can decrease, which can possibly exacerbate hypotension in children with volume depletion or shock. [emedicine.com]

• Tachycardia

  Commonest signs were tachycardia (100%) and moaning (73%). At presentation 52% were in cardiogenic shock. Response to thiamine was dramatic with moaning and irritability subsiding in two hours and tachycardia in four hours. [ncbi.nlm.nih.gov]

  Tachycardia is the most common cardiovascular effect seen with a mild metabolic acidosis. As the serum pH continues to fall below 7.2, myocardial depression occurs because hydrogen ions act as a negative inotrope and peripheral vasodilation occurs. [emedicine.com]

  Initial evaluation revealed tachycardia (111/min,) mild hypothermia (95.5 o F,) and a depressed level of consciousness with non-focal neurological examination. Blood glucose was 362 mg/dL. [thepoisonreview.com]

  Palpitation: The compensatory tachycardia will be felt as palpitation. Neurologic signs: Headache and confusion are common findings when the cerebrospinal fluid becomes acidic. [symptoma.com]

• Confusion

  You become weak or confused. You cannot be woken easily. Care Agreement You have the right to help plan your care. Learn about your health condition and how it may be treated. [drugs.com]

  Published on Feb 8, 2018 Always been confused as to what the anion gap means? Learn it in this workup to metabolic acidosis, jammed in 10 minutes of your time. Take home messages: every metabolic acidosis requires the calculation of the anion gap. [youtube.com]

  People with respiratory acidosis often have headache and confusion, and breathing may appear shallow, slow, or both. Tests on blood samples typically show pH below the normal range. Doctors treat the cause of the acidosis. [merckmanuals.com]

  Central nervous system (CNS) manifestations can include headache, lethargy, confusion, or any change in mental status secondary to a decrease in intracerebral pH. [emedicine.com]

  Some confusion may occur in patients admitted with 'collapse' and in extremis. [pathology.leedsth.nhs.uk]

• Lethargy

  Clinical presentation is heterogeneous, usually characterised by repetitive vomiting and diarrhoea, lethargy, failure to thrive until to dehydration with hypotension and shock. [ncbi.nlm.nih.gov]

  Symptoms and signs in severe cases include nausea and vomiting, lethargy, and hyperpnea. Diagnosis is clinical and with ABG and serum electrolyte measurement. The cause is treated; IV sodium bicarbonate may be indicated when pH is very low. [msdmanuals.com]

  Central nervous system (CNS) manifestations can include headache, lethargy, confusion, or any change in mental status secondary to a decrease in intracerebral pH. [emedicine.com]

  Patients with metabolic acidosis develop rapid breathing, confusion, lethargy, shock and, in untreated cases, death, according to MedlinePlus, a National Institutes of Health website. [livestrong.com]

• Stupor

  We report a 33 year-old woman addicted to chronic unspecified solvents abuse with stupor, respiratory disorders, tetraplegia and severe metabolic acidosis. [ncbi.nlm.nih.gov]

  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]

  As the acid level goes up these symptoms progress to stupor, unconsciousness, coma, and death. The breath may have a fruity odor owing to the presence of acetone, and the patient may experience vomiting and diarrhea. [medical-dictionary.thefreedictionary.com]

• Somnolence

  Lethargy and somnolence are symptoms of more severe decompensation. Patients may be hypotensive and tachycardic due to dehydration and acidosis; they may breathe rapidly and deeply to compensate for acidemia (Kussmaul respirations). [merckmanuals.com]

  Plasma VPA levels above 180 mg/mL usually have some degree of lethargy or somnolence. VPA levels have little correlation with severity of intoxication and prognosis. [clinicaladvisor.com]

• Apathy

  […] or apathy or ignorance. mt Ir-rifużjoni għandha titħallas sa mhux aktar tard minn ħames xhur wara d-data li fiha jkun intemm il-kontroll ipprovdut fl-Artikolu en Political apathy and polarisation in elections has also risen, reflecting citizens' faltering [mt.glosbe.com]

The following laboratory examinations and tests are utilized for the work up of patients with metabolic acidosis:

• Serum electrolytes: The bicarbonate (HCO3) ion is usually inadequate during metabolic acidosis. 
• Arterial blood gases (ABG): Blood gases analysis will reveal a pH level less than 7.4 during acidotic states. Concentration of HCO3 can also be determined in the ABG [4].
• Urinalysis: Urine pH may be determined from the urinalysis. Electrolytes such as sodium, chloride, and potassium can also be measured in the urine [5]. The determination of ketones in the urine is associated with diabetic, starvation, and alcoholic ketoacidosis.
• Anion gap: An increasing anion gap (AG) is indicative of an acidemic state where there is an increased number of undetected ions in the serum [6]. 
• Complete blood count: An elevated white blood cell (WBC) count may connote septicemia which could cause lactic acidosis.
• Blood urea nitrogen (BUN): This renal function test is sensitive in assessing the degree of metabolic acidosis during renal failure [7].
• Serum lactate level: An elevation of up to 3 times the normal serum lactate level is indicative of lactic ketoacidosis. 
• Salicylate level in serum: An elevated serum level of salicylate from oral medications can induce metabolic acidosis.
• Iron serum level: Iron levels exceeding 300 mg/dl is already considered toxic and could consequently lead to metabolic acidosis. 
• Electrocardiography (ECG): This test will detect rhythm abnormalities in the heart during eg. hyperkalemia.

• Hypercapnia

  The development of normocapnia or hypercapnia when a severe metabolic acidosis is present often signals respiratory muscle fatigue, impending respiratory failure, and the possible need for initiating mechanical ventilation. [emedicine.com]

  Post-hypocapnia In prolonged hypercapnia renal tubular cells compensate for a prolonged respiratory alkalosis by decreasing reclaimation and generation of HCO 3 (which takes 12-24 hrs for full affect). [nimbot.com]

  Hypercapnia is usually the result of hypoventilation rather than of increased CO2 production. [accessmedicine.mhmedical.com]

  In any condition, sodium bicarbonate may also cause sodium and volume overload, hypokalemia, and, by inhibiting respiratory drive, hypercapnia. [merckmanuals.com]

• Hypocapnia

  Blood gas analysis showed severe metabolic acidosis resulting in hypocapnia and a normal pH ( table 1 ). [anesthesiology.pubs.asahq.org]

  Post-hypocapnia In prolonged hypercapnia renal tubular cells compensate for a prolonged respiratory alkalosis by decreasing reclaimation and generation of HCO 3 (which takes 12-24 hrs for full affect). [nimbot.com]

  Mineralocorticoid Deficiency Angiotensin Deficiency: Liver Failure ACE Inhibitor Renin Deficiency Aging Extracellular fluid volume expansion Lead Beta Blocker s Prostaglandin Inhibitor Methyldopa Carbonic anhydrase inhibitor Acetazolamide Mefenamic acid Post-hypocapnia [fpnotebook.com]

  Underexcretion of CO2 produces hypercapnia, and overexcretion causes hypocapnia. Nevertheless, production and excretion are again matched at a new steady-state Paco2. [accessmedicine.mhmedical.com]

• Lactate Decreased

  Several studies report the additional prognostic usefulness of plasma lactate decrease (clearance). The best cut-off seems to be 30% lactate clearance at the sixth hour of treatment in septic shock [76]. [annalsofintensivecare.springeropen.com]

• Peaking T Wave

  As a result, hyperkalemic arrhythmias (peaked T waves and QRS widening) and ventricular fibrillation may occur. [emedicine.com]

The goal in the treatment of metabolic acidosis is to raise the serum pH to more than 7.2 to prevent life-threatening complications like cardiac arrhythmia. The most common drug used to balance metabolic acidosis is sodium bicarbonate [8]. Bicarbonate deficit is generally computed as desired HCO3 is equal to HCO3 deficit per Liter multiplied by 0.5 times body weight.

This computation will give a crude estimate of the HCO3 deficit in serum where sodium bicarbonate is administered intravenously to correct the imbalance. In the same way potassium citrate can also be given to correct metabolic acidosis with hypokalemia. Oral sodium bicarbonate is indicated for metabolic acidosis states that requires exogenous bases or alkalis to correct [9]. Researches have determined that potassium citrate may be superior to sodium bicarbonate because it requires lesser volume and does propagate the unnecessary excretion of calcium ion in the urine [10].

In general, the prognosis of metabolic acidosis is related to the underlying condition that gave rise to it. Cohort studies have shown that mortality with metabolic acidosis is usually caused by unabated acidotic states from hyperchloremia [3]. Significant morbidity is also observable among patients with uncorrected and late correction of acid-base imbalances from the time of admission. Severe uncorrected metabolic acidosis can lead to shock or death.

Medical conditions that lead to the buildup of acid in the body can potentially cause metabolic acidosis. These medical conditions include:

• Diabetic ketoacidosis
• Hyperchloremic acidosis
• Alcoholism
• Malignancy
• Liver failure
• Intense exercise
• Sepsis
• Heart failure
• Acidic medications
• Renal tubular acidosis
• Renal failure [1]
• Poisoning
• Severe dehydration

There are no exact epidemiologic data that give the incidence and prevalence of metabolic acidosis. The relative prevalence of this metabolic state is reflected in each primary disease etiology that result in this acidemic state. Moreover, metabolic acidosis is oftentimes underdiagnosed and underdocumented because metabolic acidosis is just a mere sign of a primary disease process.

In general, the basic pathophysiology of metabolic acidosis is two folds. There could be an increased acid production within any organ system or there is an inadequate production of bicarbonates from the buffering systems of the body [2]. The body regulates plasma acidity by means of these buffering systems: the bicarbonate buffering system, renal compensatory system, respiratory compensatory system, and the intracellular absorption of hydrogen atoms. The bicarbonate system receives the hydrogen from the acidic compounds and neutralizes them into carbon dioxide and water. Any imbalance in the buffering system moves the pH lower than 7.4 making the serum acidic.

Prevention of metabolic acidosis is grossly dependent on the primary prevention of its underlying causes. Diabetic control is essential to prevent diabetic ketoacidosis from ensuing. Alcohol should be taken in moderation to avoid alcoholic ketoacidosis from taking place. Athletic sports and exercises should be done in moderation to prevent lactic acidosis from developing. The injudicious use of salicylate-base pain relievers and iron supplements must be checked to prevent it’s toxicity that may lead to metabolic acidosis.

Metabolic acidosis is defined as a medical condition where there is an imbalance of the acid-base ions causing plasma acidity. The metabolic acidosis state is usually a sign of underlying disease process. Correction of the primary cause of the metabolic imbalance will normalize or reverse the metabolic state. An indepth understanding of the nature of the acid-base regulation mechanism is required to understand the complex processes that give rise to metabolic acidosis.

• Definition: Metabolic acidosis is defines as a clinical condition where there is an imbalance of the acid-base ions causing too much acid in plasma.
• Cause: Ketoacidosis is the leading cause of metabolic acidosis which could be brought about by diabetes, alcoholism, starvation, and cancer. Hyperchloremic states with diarrhea and vomiting may also induce acidemic states in the serum.
• Symptoms: Acidotic patients will present with varying degrees of dyspnea, hyperventilation, chest pains, palpitation, and bone pain. 
• Diagnosis: The ideal workup for metabolic acidosis include ABG, CBC, serum lactate levels, and ECG readings. 
• Treatment and follow-up: The prompt correction of the acidemic state is imperative to prevent life-threatening arrhythmia. Patients may be given sodium bicarbonate intravenously, oral sodium bicarbonate, and potassium citrate to correct the metabolic acidosis.

1. 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.
2. Mitch WE. Metabolic and clinical consequences of metabolic acidosis. J Nephrol. 2006; 19 Suppl 9:S70-5 (ISSN: 1121-8428)
3. Maciel AT, Park M. Differences in acid-base behavior between intensive care unit survivors and nonsurvivors using both a physicochemical and a standard base excess approach: a prospective, observational study. J Crit Care. Dec 2009; 24(4):477-83.
4. Schauer KL, Freund DM, Prenni JE, Curthoys NP. Proteomic profiling and pathway analysis of the response of rat renal proximal convoluted tubules to metabolic acidosis. Am J Physiol Renal Physiol. 2013; 305(5):F628-40 
5. Pereira PC, Miranda DM, Oliveira EA, Silva AC. Molecular pathophysiology of renal tubular acidosis. Curr Genomics. Mar 2009; 10(1):51-9.
6. Reddy P, Mooradian AD. Clinical utility of anion gap in deciphering acid-base disorders. Int J Clin Pract. Oct 2009; 63(10):1516-25.
7. Mathur RP, Dash SC, Gupta N, Prakash S. Effects of correction of metabolic acidosis on blood urea and bone metabolism in patients with mild to moderate chronic kidney disease: a prospective randomized single blind controlled trial. Ren Fail. 2006; 28(1):1-5.
8. Goraya N, Simoni J, Jo CH, Wesson DE. A comparison of treating metabolic acidosis in CKD stage 4 hypertensive kidney disease with fruits and vegetables or sodium bicarbonate. Clin J Am Soc Nephrol. Mar 2013; 8(3):371-81.
9. Abramowitz MK, Melamed ML, Bauer C, Raff AC, Hostetter TH. Effects of oral sodium bicarbonate in patients with CKD. Clin J Am Soc Nephrol. May 2013; 8(5):714-20.
10. Starke A, Corsenca A, Kohler T, Knubben J, Kraenzlin M, Uebelhart D, et al. Correction of metabolic acidosis with potassium citrate in renal transplant patients and its effect on bone quality. Clin J Am Soc Nephrol. Sep 2012; 7(9):1461-72.