Management The management of metabolic acidosis should focus on the identification and treatment of the underlying cause and ensuring adequate perfusion The immediate therapy of metabolic acidosis in the ED generally depends on the severity of the disorder In children with severe acidemia (serum pH less than 7.10), bicarbonate therapy is generally indicated The basis for correcting severe acidosis is the negative impact severe acidemia has on cardiac function, including impaired cardiac contractility and increased risk for cardiac arrhythmias Exceptions would include metabolic acidosis in patients with DKA, as lower thresholds for pH are allowed before bicarbonate is provided given the expected metabolism of ketoacid into bicarbonate with insulin and fluid repletion (see Chapter 89 Endocrine Emergencies ) The role of alkali therapy remains controversial in hypoperfusion lactic acidosis and is yet to be resolved The aim of treatment in hypoperfusion lactic acidosis is to restore intravascular volume and perfusion in a timely fashion, which will allow metabolism of lactate anions to bicarbonate The potential complications of alkali therapy in metabolic acidosis include hypercarbia, hypernatremia, transcellular shift of potassium ion into the intracellular space resulting in hypokalemia, and alkalosis Furthermore, alkalosis or an increase in blood pH may precipitate tetany by promoting binding of calcium to albumin, which reduces the ionized calcium concentration When bicarbonate therapy is to be given, estimating the necessary dose may prove to be challenging Given the difficulty in accurately estimating the bicarbonate deficit, bicarbonate can be given at an initial dose of 0.5 to mEq/kg if clinically indicated with the aim of increasing the systemic pH to more than 7.20 Further alkali therapy will depend upon the response and subsequent disease course If the patient is asymptomatic, the underlying process can be controlled (e.g., diarrheal dehydration), and tissue perfusion can be assured, alkali therapy may not be required In the setting of asymptomatic chronic metabolic acidosis, such as RTA and CKD, consultation with an appropriate specialist would be reasonable to guide oral therapy and avoid complications such as electrolyte derangements and volume excess Metabolic Alkalosis