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Approach to the patient with metabolic acidosis: Newer concepts

Summary: A new classification for patients with metabolic acidosis is provided: a pathophysiological classification. to recognize an overproduction of acids which results in a hydrogen ion (H+) gain the number of new anions retained in the body is added to those excreted in the urine when the cation accompanying them was not H+ or ammonium (NH4+). the first tools are to recognize new anions that were added during the overproduction of acids. the nature of these anions can be recognized by assessing their fractional excretion. the second set of tools focuses on an assessment of NH4+ in the urine using urine anion and osmolar gaps. the clinical approach suggested focuses on detecting an emergency (severity of H+ accumulation, toxic alcohols and/or dyskalaemias). the second step analyzes the expected responses to acidaemia; here the focus is on the PCO2 in vital organs and the rate of excretion of ammonium. the principles used for diagnosis and treatment of metabolic acidosis are illustrated by a case example.