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- Andrew L. Schwaderer, MD*
- George J. Schwartz, MD†
- *Fellow, Pediatric Nephrology, University of Rochester School of Medicine & Dentistry
- †Professor of Pediatrics; Chief, Pediatric Nephrology, University of Rochester School of Medicine & Dentistry, Rochester, NY
Objectives
After completing this article, readers should be able to:
Plan initial therapy for severe acidosis (metabolic).
Know the differential diagnosis of acidosis associated with a high anion gap.
Discuss the consequences of chronic volume contraction.
Describe the pulmonary compensatory changes seen in primary metabolic alkalosis.
Describe the renal compensatory changes seen in primary respiratory acidosis and in primary respiratory alkalosis.
Delineate which diuretics produce metabolic alkalosis and which produce metabolic acidosis.
Case Study
A 20-kg child presents with the primary complaints of several days of diarrhea, poor intake, and decreased urine output. On physical examination, the patient has a respiratory rate of 30 breaths/min and mildly dry mucous membranes. Laboratory evaluation demonstrates: sodium, 135 mEq/L (135 mmol/L); potassium, 4.0 mEq/L (4.0 mmol/L); chloride, 120 mEq/L (120 mmol/L); bicarbonate, 4 mEq/L (4 mmol/L); blood urea nitrogen, 10 mg/dL (3.6 mmol/L); creatinine, 0.5 mg/dL (44.2 mcmol/L); glucose, 100 mg/dL (5.6 mmol/L); arterial pH, 7.02; and Pco2, 16 mm Hg. What needs to be considered in the differential diagnosis? Is intravenous hydration alone adequate for therapy?
Introduction
Acid-base disorders, which may be caused by a variety of underlying conditions, are encountered frequently in both inpatient and outpatient settings. Because many variables are involved in the regulation of acid-base homeostasis, the clinical approach to these disturbances may seem confusing. A basic understanding of the physiology, evaluation, and treatment of acid-base disorders can help the pediatrician to prevent the consequences of altered acid-base homeostasis.
An acid is a substance capable of donating protons (hydrogen ions), and a base is a substance capable of receiving protons. The body’s extracellular hydrogen ion (H+) concentration is extremely small, less than one-millionth the concentration of sodium (Na+). The negative logarithm of the hydrogen ion concentration is the pH, and this determination is clinically most useful.
The normal …
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