Pediatric Metabolic Alkalosis

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Metabolic alkalosis is an acid-base disturbance caused by an elevation in the plasma bicarbonate (HCO3) concentration. This condition is not a disease; it is a sign or state encountered in certain disease processes. Although metabolic alkalosis may not be referred to as often as metabolic acidosis, it is the most common acid-base abnormality in hospitalized adults, [1] particularly those in the intensive care unit (ICU). [2] Alkalosis refers to a loss of acid or gain of base in the extracellular fluid (ECF); alkalemia refers to a change in blood pH. Alkalosis is not necessarily accompanied by alkalemia.

The two types of metabolic alkalosis (ie, chloride-responsive, chloride-resistant) are classified based on the amount of chloride in the urine.

Chloride-responsive metabolic alkalosis involves urine chloride levels of less than 20 mEq/L, is typically found to be below 10 mEq/L, and is characterized by decreased ECF volume and low serum chloride levels, such as occurs with vomiting. This type responds to administration of chloride salt.

Chloride-resistant metabolic alkalosis involves urine chloride levels above 20 mEq/L and is characterized by increased ECF volume. As the name implies, this type resists administration of chloride salt. Primary aldosteronism is an example of chloride-resistant metabolic alkalosis.

For a review of metabolic alkalosis in patients of all ages, see Metabolic Alkalosis.

Causes of metabolic alkalosis include the following:

The consequences of metabolic alkalosis on organ systems depend on the severity of the alkalemia and the degree of respiratory compensation. Mild to moderate metabolic alkalosis is rarely clinically significant in isolation. If the elevated plasma HCO3 concentration is not accompanied by a rise in the partial pressure of carbon dioxide (PCO2), the elevation of pH is much more severe.

The respiratory effects of metabolic alkalosis are two-fold. An increase in blood pH shifts the oxygen-hemoglobin dissociation curve to the left. This creates a tighter bond between hemoglobin and oxygen, causing decreased oxygen delivery to tissues. Hypoxemia may be worsened by a compensatory hypoventilation to elevate PCO2. Hypoventilation may be severe enough to cause apnea and respiratory arrest.

Cardiovascular effects often result from the association of hypokalemia with metabolic alkalosis. Life-threatening arrhythmias are the most significant adverse effect of metabolic alkalosis. Direct arteriolar constriction is further worsened by electrolyte disturbances. Ventricular and supraventricular arrhythmias that are often unresponsive to antiarrhythmic agents can occur.

Neuromuscular effects of severe metabolic alkalosis may include headache, seizures, and obtundation, as well as marked muscle weakness. These resolve only with correction of the pH.

Electrolyte imbalances in metabolic alkalosis include a decrease in ionized calcium levels due to the increased binding of calcium to plasma proteins; consequences include tetany and seizures. Total-body potassium loss may contribute to alkalemia, in which serum potassium is intracellularly shifted. Weakness and cardiac arrhythmias may result from severe hypokalemia.

The body compensates for metabolic alkalosis through buffering of excess HCO3 and hypoventilation. Intracellular buffering occurs through sodium/hydrogen and potassium/hydrogen ion exchange, with eventual formation of CO2 and water from HCO3.

Within several hours, elevated levels of HCO3 and metabolic alkalosis stimulate a chemoreceptor inhibition of the respiratory center, resulting in hypoventilation and increased PCO2 levels. This mechanism produces a rise in PCO2 of as much as 0.7 mm Hg for each 1-mEq/L increase in HCO3. [3] Hypoventilation may cause hypoxemia.

As noted earlier, etiologically, metabolic alkalosis can be divided into chloride-responsive alkalosis (urine chloride 20 mEq/L).

Causes of chloride-responsive metabolic alkalosis include the following:

Causes of chloride-resistant metabolic alkalosis include the following:

Regarding gastric losses (eg, vomiting, NG drainage), bicarbonate (HCO3) produced by the pancreas normally neutralizes the hydrochloric acid (HCl) produced by the gastric mucosa, so that no net gain or loss of hydrogen ions or bicarbonate occurs. When gastric acid is lost through vomiting or removed by suction, plasma HCO3 levels increase. In addition, the loss of potassium and volume contraction due to vomiting potentiate metabolic alkalosis.

Diuretics produce increased renal losses of sodium, which is followed by excretion of chlorides. To maintain electrical neutrality in the extracellular fluid (ECF), HCO3 reabsorption in the renal tubules increases. Additionally, increased sodium levels in the distal tubules increases sodium-potassium exchange. The loss of potassium, in turn, leads to intracellular accumulation of hydrogen ions and their secretion in the distal tubules. Diuretics also promote the loss of magnesium in the urine, which further lowers potassium levels through an unknown mechanism.

Volume contraction concentrates the existing levels of HCO3 in the ECF. In addition, it stimulates release of renin-angiotensin, which causes increased potassium and hydrogen ion losses in the kidney.

Regarding posthypercapnia syndrome, chronic carbon dioxide (CO2) retention causes a compensatory increase in HCO3 levels. When a patient with chronic CO2 retention receives treatment that abruptly drops the CO2 level, metabolic alkalosis becomes evident.

Because metabolic alkalosis is a manifestation of a disease process rather than a disease itself, the true incidence is unknown. In a review of 2000 hospitalized adults, Hodgkin et al noted that metabolic alkalosis was the most common acid-base disorder. [6]  It has been estimated that metabolic alkalosis comprises about half of all acid-base disorders in hospitalized patients. [1]

No racial or sexual differences in incidence have been noted, and metabolic alkalosis can occur in people of any age. However, a higher incidence of metabolic alkalosis after cardiac surgery in younger children has been reported. [7, 8, 9]

The overall prognosis in patients with metabolic alkalosis depends on the underlying etiology. Chloride-responsive metabolic alkalosis responds to volume resuscitation and chloride repletion. Chloride-resistant metabolic alkalosis may be more difficult to control. The prognosis is good with prompt treatment and avoidance of hypoxemia.

Severe metabolic alkalosis is associated with increased morbidity and mortality, probably because of its profound influences on multiple organ systems and, more importantly, because of tissue anoxia caused by hypoventilation and shift of the oxygen-dissociation curve to the left. [10]

Severe metabolic alkalosis can lead to hypoventilation; as noted above, the resultant hypoxemia is compounded by a shift of the oxygen-hemoglobin dissociation curve to the left. In extreme cases, hypoventilation may be severe enough to require mechanical ventilation or to interfere with weaning from current mechanical ventilation.

Intracellular shift of potassium in severe alkalemia may lead to life-threatening arrhythmias or cardiac arrest.

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Lennox H Huang, MD, FAAP Chief Medical Officer, The Hospital for Sick Children; Associate Professor of Pediatrics, University of Toronto Faculty of Medicine; Associate Clinical Professor of Pediatrics, McMaster University School of Medicine, Canada

Lennox H Huang, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for Physician Leadership, Canadian Medical Association, Ontario Medical Association, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Margaret A Priestley, MD Associate Professor of Clinical Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania; Clinical Director, Pediatric Intensive Care Unit, The Children’s Hospital of Philadelphia

Margaret A Priestley, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Jonathan Sniderman, MD Fellow in Pediatric Intensive Care, Department of Pediatrics, University of Toronto Faculty of Medicine, Canada

Jonathan Sniderman, MD is a member of the following medical societies: Canadian Medical Association, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Barry J Evans, MD Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children’s Medical Center

Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Timothy E Corden, MD Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children’s Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, Wisconsin Medical Society

Disclosure: Nothing to disclose.

G Patricia Cantwell, MD, FCCM Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami Leonard M Miller School of Medicine/ Holtz Children’s Hospital, Jackson Memorial Medical Center; Medical Director, Palliative Care Team, Holtz Children’s Hospital; Medical Manager, FEMA, South Florida Urban Search and Rescue, Task Force 2

G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

Pediatric Metabolic Alkalosis

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