Diagnosis and management of metabolic acidosis: guidelines from a French expert panel

Boris Jung, Mikaël Martinez, Yann-Erick Claessens, Michaël Darmon, Kada Klouche, Alexandre Lautrette, Jacques Levraut, Eric Maury, Mathieu Oberlin, Nicolas Terzi, Damien Viglino, Youri Yordanov, Pierre-Géraud Claret, Naïke Bigé, Société de Réanimation de Langue Française (SRLF), Société Française de Médecine d’Urgence (SFMU), Boris Jung, Mikaël Martinez, Yann-Erick Claessens, Michaël Darmon, Kada Klouche, Alexandre Lautrette, Jacques Levraut, Eric Maury, Mathieu Oberlin, Nicolas Terzi, Damien Viglino, Youri Yordanov, Pierre-Géraud Claret, Naïke Bigé, Société de Réanimation de Langue Française (SRLF), Société Française de Médecine d’Urgence (SFMU)

Abstract

Metabolic acidosis is a disorder frequently encountered in emergency medicine and intensive care medicine. As literature has been enriched with new data concerning the management of metabolic acidosis, the French Intensive Care Society (Société de Réanimation de Langue Française [SRLF]) and the French Emergency Medicine Society (Société Française de Médecine d'Urgence [SFMU]) have developed formalized recommendations from experts using the GRADE methodology. The fields of diagnostic strategy, patient assessment, and referral and therapeutic management were addressed and 29 recommendations were made: 4 recommendations were strong (Grade 1), 10 were weak (Grade 2), and 15 were experts' opinions. A strong agreement from voting participants was obtained for all recommendations. The application of Henderson-Hasselbalch and Stewart methods for the diagnosis of the metabolic acidosis mechanism is discussed and a diagnostic algorithm is proposed. The use of ketosis and venous and capillary lactatemia is also treated. The value of pH, lactatemia, and its kinetics for the referral of patients in pre-hospital and emergency departments is considered. Finally, the modalities of insulin therapy during diabetic ketoacidosis, the indications for sodium bicarbonate infusion and extra-renal purification as well as the modalities of mechanical ventilation during severe metabolic acidosis are addressed in therapeutic management.

Keywords: Anion gap; Blood gas analysis; Hyperlactatemia; Ketoacidosis; Metabolic acidosis; Renal replacement therapy; Sodium bicarbonate.

Conflict of interest statement

The authors declare the following competing interests: B. Jung: Sedana Medical, Medtronic; M. Martinez: Astra Zeneca, Actélion; YE Claessens: Roche diagnostics, BioMérieux, Sanofi, Pfizer; M. Darmon: Sanofi, Gilead-Kite, Astute Medical, MSD, Astellas; A. Lautrette: Baxter, Frésénius; J. Levraut: LFB, Nova-Biomedical; E. Maury: General Electric Healthcare, Doran International, Vygon, AstraZeneca; N. Terzi: Boehringer Ingelheim, Pfizer; D. Viglino: Astra Zeneca, Mundipharma; Y. Yordanov: Mundipharma, Sanofi; PG Claret: Aspen, AstraZeneca, Daiichi Sankyo, Roche Diagnostics, Sanofi, Thermo Fisher Scientific. The remaining authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Algorithm recommended by the experts for etiological diagnosis of metabolic acidemia (EXPERT OPINION)

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