Urgent considerations
See Differentials for more details
Severe metabolic alkalosis (arterial pH >7.6) requires immediate attention and treatment, as it may lead to life-threatening seizures and ventricular arrhythmias.
Arterial pH is rapidly reduced by controlled hypoventilation, using sedation and mechanical ventilation. Volume depletion can be corrected with normal saline, and electrolyte abnormalities such as hypokalaemia should also be corrected.[18][19]
Alternative treatments, such as giving hydrogen chloride (HCl) or ammonium chloride, are indicated if normal saline is contraindicated (e.g., in cases of fluid overload) but have a high risk of complications (haemolysis and tissue necrosis with HCl and ammonia toxicity with ammonium chloride).[2] HCl solution can be given over a period of 6 to 8 hours through a central vein.
In presence of fluid overload, the diuretic acetazolamide, a carbonic anhydrase inhibitor that acts by decreasing the reabsorption of sodium bicarbonate (NaHCO₃) in the proximal tubule, can be used.
Haemodialysis with a low bicarbonate bath may be needed to correct severe metabolic alkalosis in patients with advanced kidney failure.
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