Metabolische Azidose

Störungen des Säure-Basen-Haushalts (SBH) unterschiedlicher Ätiologie kommen im klinischen Alltag sehr häufig vor. Jeder klinisch tätige Arzt sollte daher die Erkennung und Therapie von Störungen im SBH beherrschen, um Patienten mit diesen Störungen optimal zu behandeln.

Abstract

Acid-base disorders due to different etiologies are frequently encountered in daily clinical practice and may result in life-threatening situations. Basic knowledge of the diagnostic and therapeutic approach of acid-base disorders is therefore essential for every clinician. Acid-base disorders should be treated according to their underlying etiology. Therefore, diagnosis of the underlying etiology is the critical step in the process of care for patients with acid-base disorders. Undirected buffering with HCO₃ ^– should be avoided, since the application of HCO₃ ^– might lead to severe side effects. A strict diagnostic pathway for the diagnosis of acid-base disorders is required, which should be vigorously applied:

– analysis of the pH to classify acidemia or alkalemia

– analysis of pCO₂ and HCO₃ ^– to classify the primary acid base disorder

– analysis of the adequate regulation in order to detect additional acid-base disorders

– analysis of the anion gap and the relationship of the anion gap vs. the change in HCO₃ ^– to detect further metabolic disorders

Metabolic acidosis can be divided into two main etiologies:

– acidosis with addition of acid with increased anion gap,

– acidosis with loss of HCO₃ ^– with normal anion gap.

Schlüsselwörter

Säure-Basen-Störung - metabolische Azidose - metabolische Alkalose - Anionenlücke

Key words

acid base disorders - metabolic acidosis - metabolic alkalosis - anion gap

Publication History

Article published online:
03 November 2020

• Literatur

• 1 Adrogue HJ, Gennari FJ, Galla JH. et al Assessing acid-base disorders. Kidney Int 2009; 76: 1239-1247 . doi:10.1038/ki.2009.359
• 2 Kimura S, Shabsigh M, Morimatsu H. Traditional approach versus Stewart approach for acid-base disorders: Inconsistent evidence. SAGE Open Med 2018; 6: 2050312118801255 . doi:10.1177/2050312118801255
• 3 Lehner LJ, Oppert M, Kettritz R. Schwere Azidose. Nephrologe 2019; 14: 431-437
• 4 Kamel KS, Halperin ML. Acid-base problems in diabetic ketoacidosis. NEJM 2015; 372: 1969-1970 . doi:10.1056/NEJMc1502745
• 5 Kitterer D. Azidose. In: Alscher MD. Hrsg. Referenz Nephrologie. 1. Aufl. Georg Thieme Verlag; 2019. DOI: 10.1055/b-005-143660
• 6 Feldkamp T. Das akute Nierenversagen. In: Alscher MD. Hrsg Referenz Nephrologie. 1. Aufl. Georg Thieme Verlag; 2019. DOI: 10.1055/b-005–143660
• 7 Bellingham AJ, Detter JC, Lenfant C. Regulatory mechanisms of hemoglobin oxygen affinity in acidosis and alkalosis. J Clin Invest 1971; 50: 700-706 . doi:10.1172/JCI106540
• 8 Almeida AR, Wetzels JF, Bunnachak D. et al Acute phosphate depletion and in vitro rat proximal tubule injury: protection by glycine and acidosis. Kidney Int 1992; 41: 1494-1500 . doi:10.1038/ki.1992.218
• 9 Jung B, Jaber S. The Janus faces of bicarbonate therapy in the ICU. Intensive Care Med 2019; 46: 516-518 . doi:10.1007/s00134-019-05835-3
• 10 Rhodes A, Evans LE, Alhazzani W. et al Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017; 43: 304-377 . doi:10.1007/s00134-017-4683-6
• 11 Lo KB, Garvia V, Stempel JM. et al Bicarbonate use and mortality outcome among critically ill patients with metabolic acidosis: A meta analysis. Heart Lung 2019; 49 (02) 167-174 . doi:10.1016/j.hrtlng.2019.10.007
• 12 Jaber S, Paugam C, Futier E. et al Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomised controlled, phase 3 trial. Lancet 2018; 392: 31-40 . doi:10.1016/S0140-6736(18)31080-8
• 13 Zhang Z, Zhu C, Mo L. et al Effectiveness of sodium bicarbonate infusion on mortality in septic patients with metabolic acidosis. Intensive Care Med 2018; 44: 1888-1895 . doi:10.1007/s00134-018-5379-2
• 14 Kettritz R, Luft FC. Störungen des Säure-Base-Haushalts. In: Alscher MD, Böhler J, Kuhlmann U. et al., Hrsg. Nephrologie. 6. Aufl. Georg Thieme Verlag; 2015. DOI: 10.1055/b-003-124668
• 15 Hamilton PK, Morgan NA, Connolly GM. et al Understanding acid-base disorders. Ulster Med J 2017; 86: 161-166
• 16 Barski L, Eshkoli T, Brandstaetter E. et al Euglycemic diabetic ketoacidosis. Eur J Int Med 2019; 63: 9-14 . doi:10.1016/j.ejim.2019.03.014
• 17 Kraut JA, Mullins ME. Toxic alcohols. NEJM 2018; 378: 270-280 . doi:10.1056/NEJMra1615295
• 18 Hanif M, Mobarak MR, Ronan A. et al Fatal renal failure caused by diethylene glycol in paracetamol elixir: the Bangladesh epidemic. BMJ 1995; 311: 88-91 . doi:10.1136/bmj.311.6997.88
• 19 Schricker S, Schanz M, Alscher MD. et al Metabolische Azidose. Diagnostik und Therapie. Medizinische Klinik, Intensivmedizin und Notfallmedizin 2019; DOI: 10.1007/s00063-019-0538-y.
• 20 Juurlink DN, Gosselin S, Kielstein JT. et al Extracorporeal treatment for salicylate poisoning: systematic review and recommendations from the EXTRIP Workgroup. Ann Emerg Med 2015; 66: 165-181 . doi:10.1016/j.annemergmed.2015.03.031
• 21 Weiler S, Bellmann R, Kullak-Ublick GA. 5-Oxoprolin (Pyroglutaminsäure) Azidose unter Paracetamol – Eine Differentialdiagnose der metabolischen Azidose mit erhöhter Anionenlücke. Ther Umschau 2015; 72: 737-741 . doi:10.1024/0040-5930/a000745
• 22 Teloh JK, Waack IN, de Groot H. Prompt rise in urinary ammonium excretion suffices to mitigate metabolic acidosis in an experimental animal model of severe normovolemic hemodilution. Physiol Res 2017; 66: 615-620 . doi:10.33549/physiolres.933491
• 23 Alexander RT, Bitzan M. Renal Tubular acidosis. Pediat Clin North Am 2019; 66: 135-157 . doi:10.1016/j.pcl.2018.08.011