{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,22]],"date-time":"2026-10-22T14:05:16Z","timestamp":1792677916373,"version":"4.5.0"},"reference-count":65,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"1","content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":["CJASN"],"published-print":{"date-parts":[[2023,1]]},"abstract":"<jats:p>\n                    Acid-base disorders are common in the intensive care unit. By utilizing a systematic approach to their diagnosis, it is easy to identify both simple and mixed disturbances. These disorders are divided into four major categories: metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis. Metabolic acidosis is subdivided into anion gap and non\u2013gap acidosis. Distinguishing between these is helpful in establishing the cause of the acidosis. Anion gap acidosis, caused by the accumulation of organic anions from sepsis, diabetes, alcohol use, and numerous drugs and toxins, is usually present on admission to the intensive care unit. Lactic acidosis from decreased delivery or utilization of oxygen is associated with increased mortality. This is likely secondary to the disease process, as opposed to the degree of acidemia. Treatment of an anion gap acidosis is aimed at the underlying disease or removal of the toxin. The use of therapy to normalize the pH is controversial. Non\u2013gap acidoses result from disorders of renal tubular H\n                    <jats:sup>+<\/jats:sup>\n                    transport, decreased renal ammonia secretion, gastrointestinal and kidney losses of bicarbonate, dilution of serum bicarbonate from excessive intravenous fluid administration, or addition of hydrochloric acid. Metabolic alkalosis is the most common acid-base disorder found in patients who are critically ill, and most often occurs after admission to the intensive care unit. Its etiology is most often secondary to the aggressive therapeutic interventions used to treat shock, acidemia, volume overload, severe coagulopathy, respiratory failure, and AKI. Treatment consists of volume resuscitation and repletion of potassium deficits. Aggressive lowering of the pH is usually not necessary. Respiratory disorders are caused by either decreased or increased minute ventilation. The use of permissive hypercapnia to prevent barotrauma has become the standard of care. The use of bicarbonate to correct the acidemia is not recommended. In patients at the extreme, the use of extracorporeal therapies to remove CO\n                    <jats:sub>2<\/jats:sub>\n                    can be considered.\n                  <\/jats:p>","DOI":"10.2215\/cjn.04500422","type":"journal-article","created":{"date-parts":[[2022,8,23]],"date-time":"2022-08-23T11:26:20Z","timestamp":1661253980000},"page":"102-112","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":142,"title":["Acid-Base Disorders in the Critically Ill Patient"],"prefix":"10.2215","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2275-6864","authenticated-orcid":false,"given":"Anand","family":"Achanti","sequence":"first","affiliation":[{"name":"Internal Medicine\/Nephrology, Medical University of South Carolina, Charleston, South Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3841-3172","authenticated-orcid":false,"given":"Harold M.","family":"Szerlip","sequence":"additional","affiliation":[{"name":"Internal Medicine\/Nephrology, Medical University of South Carolina, Charleston, South Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2022,8,23]]},"reference":[{"key":"B1-20250823","doi-asserted-by":"crossref","first-page":"1104","DOI":"10.1093\/ndt\/gfu289","article-title":"Acid-base disturbances in intensive care patients: Etiology, pathophysiology and treatment","volume":"30","author":"Al-Jaghbeer","year":"2015","journal-title":"Nephrol Dial Transplant"},{"key":"B2-20250823","doi-asserted-by":"crossref","first-page":"1444","DOI":"10.1139\/y83-207","article-title":"Modern quantitative acid-base chemistry","volume":"61","author":"Stewart","year":"1983","journal-title":"Can J Physiol Pharmacol"},{"key":"B3-20250823","doi-asserted-by":"crossref","first-page":"62","DOI":"10.5492\/wjccm.v4.i1.62","article-title":"Has Stewart approach improved our ability to diagnose acid-base disorders in critically ill patients?","volume":"4","author":"Masevicius","year":"2015","journal-title":"World J Crit Care Med"},{"key":"B4-20250823","doi-asserted-by":"crossref","first-page":"F1009","DOI":"10.1152\/ajprenal.00475.2007","article-title":"Acid-base analysis: A critique of the Stewart and bicarbonate-centered approaches","volume":"294","author":"Kurtz","year":"2008","journal-title":"Am J Physiol Renal Physiol"},{"key":"B5-20250823","doi-asserted-by":"crossref","first-page":"374","DOI":"10.1213\/ANE.0000000000005501","article-title":"Comparing central venous blood gas to arterial blood gas and determining its utility in critically ill patients: Narrative review","volume":"133","author":"Chong","year":"2021","journal-title":"Anesth Analg"},{"key":"B6-20250823","doi-asserted-by":"crossref","first-page":"293","DOI":"10.1159\/000488501","article-title":"Accuracy of acid-base diagnoses using the central venous blood gas in the medical intensive care unit","volume":"139","author":"Schrauben","year":"2018","journal-title":"Nephron"},{"key":"B7-20250823","doi-asserted-by":"crossref","first-page":"1807","DOI":"10.1097\/00003246-199811000-00019","article-title":"Anion gap and hypoalbuminemia","volume":"26","author":"Figge","year":"1998","journal-title":"Crit Care Med"},{"key":"B8-20250823","doi-asserted-by":"crossref","first-page":"854","DOI":"10.1056\/NEJM198010093031505","article-title":"Diagnostic importance of an increased serum anion gap","volume":"303","author":"Gabow","year":"1980","journal-title":"N Engl J Med"},{"key":"B9-20250823","doi-asserted-by":"crossref","first-page":"892","DOI":"10.1016\/S0140-6736(08)61398-7","article-title":"GOLD MARK: An anion gap mnemonic for the 21st century","volume":"372","author":"Mehta","year":"2008","journal-title":"Lancet"},{"key":"B10-20250823","doi-asserted-by":"crossref","first-page":"255","DOI":"10.1177\/0885066605278644","article-title":"Lactic acidosis: From sour milk to septic shock","volume":"20","author":"Fall","year":"2005","journal-title":"J Intensive Care Med"},{"key":"B11-20250823","doi-asserted-by":"crossref","first-page":"1178633719862776","DOI":"10.1177\/1178633719862776","article-title":"Lactate predicts both short- and long-term mortality in patients with and without sepsis","volume":"12","author":"Villar","year":"2019","journal-title":"Infect Dis (Auckl)"},{"key":"B12-20250823","doi-asserted-by":"crossref","first-page":"122","DOI":"10.1177\/0885066607312985","article-title":"Anion gap, anion gap corrected for albumin, and base deficit fail to accurately diagnose clinically significant hyperlactatemia in critically ill patients","volume":"23","author":"Chawla","year":"2008","journal-title":"J Intensive Care Med"},{"key":"B13-20250823","doi-asserted-by":"crossref","first-page":"627","DOI":"10.1136\/emj.2005.031898","article-title":"Correcting the anion gap for hypoalbuminaemia does not improve detection of hyperlactataemia","volume":"23","author":"Dinh","year":"2006","journal-title":"Emerg Med J"},{"key":"B14-20250823","doi-asserted-by":"crossref","first-page":"275","DOI":"10.1097\/00003246-199003000-00005","article-title":"Low sensitivity of the anion gap as a screen to detect hyperlactatemia in critically ill patients","volume":"18","author":"Iberti","year":"1990","journal-title":"Crit Care Med"},{"key":"B15-20250823","doi-asserted-by":"crossref","first-page":"382","DOI":"10.1016\/j.amjms.2018.06.015","article-title":"Thiamine deficiency: An important consideration in critically ill patients","volume":"356","author":"Attaluri","year":"2018","journal-title":"Am J Med Sci"},{"key":"B17-20250823","doi-asserted-by":"crossref","first-page":"270","DOI":"10.1056\/NEJMra1615295","article-title":"Toxic alcohols","volume":"378","author":"Kraut","year":"2018","journal-title":"N Engl J Med"},{"key":"B18-20250823","doi-asserted-by":"crossref","first-page":"623","DOI":"10.4103\/1947-2714.120804","article-title":"Bilateral putaminal hemorrhages: Serious complication of methanol intoxication","volume":"5","author":"Permpalung","year":"2013","journal-title":"N Am J Med Sci"},{"key":"B19-20250823","doi-asserted-by":"crossref","first-page":"521","DOI":"10.1002\/ncp.10329","article-title":"Folate as an adjuvant therapy in methanol poisoning","volume":"34","author":"Theobald","year":"2019","journal-title":"Nutr Clin Pract"},{"key":"B21-20250823","doi-asserted-by":"crossref","first-page":"1674","DOI":"10.1378\/chest.128.3.1674","article-title":"Propylene glycol toxicity: A severe iatrogenic illness in ICU patients receiving IV benzodiazepines: A case series and prospective, observational pilot study","volume":"128","author":"Wilson","year":"2005","journal-title":"Chest"},{"key":"B22-20250823","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1592\/phco.30.2.219","article-title":"Severe lactic acidosis after an iatrogenic propylene glycol overdose","volume":"30","author":"Zosel","year":"2010","journal-title":"Pharmacotherapy"},{"key":"B23-20250823","doi-asserted-by":"crossref","first-page":"163","DOI":"10.1081\/CLT-120030942","article-title":"Unusual D-lactic acid acidosis from propylene glycol metabolism in overdose","volume":"42","author":"Jorens","year":"2004","journal-title":"J Toxicol Clin Toxicol"},{"key":"B24-20250823","doi-asserted-by":"crossref","first-page":"191","DOI":"10.2215\/CJN.07730713","article-title":"Acetaminophen toxicity and 5-oxoproline (pyroglutamic acid): A tale of two cycles, one an ATP-depleting futile cycle and the other a useful cycle","volume":"9","author":"Emmett","year":"2014","journal-title":"Clin J Am Soc Nephrol"},{"key":"B25-20250823","doi-asserted-by":"crossref","first-page":"162","DOI":"10.1186\/s13054-019-2450-5","article-title":"Pyroglutamic acidosis by glutathione regeneration blockage in critical patients with septic shock","volume":"23","author":"Gamarra","year":"2019","journal-title":"Crit Care"},{"key":"B26-20250823","doi-asserted-by":"crossref","first-page":"507","DOI":"10.1016\/j.metabol.2015.12.007","article-title":"The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management","volume":"65","author":"Nyenwe","year":"2016","journal-title":"Metabolism"},{"key":"B27-20250823","doi-asserted-by":"crossref","first-page":"658","DOI":"10.1016\/j.jemermed.2021.09.007","article-title":"Alcoholic ketoacidosis: Etiologies, evaluation, and management","volume":"61","author":"Long","year":"2021","journal-title":"J Emerg Med"},{"key":"B28-20250823","doi-asserted-by":"crossref","first-page":"1481","DOI":"10.1001\/archinte.1978.03630350019008","article-title":"Acid-base disturbances in the salicylate-intoxicated adult","volume":"138","author":"Gabow","year":"1978","journal-title":"Arch Intern Med"},{"key":"B29-20250823","first-page":"550","article-title":"Effect of urinary pH on the pharmacokinetics of salicylic acid, with its glycine and glucuronide conjugates in human","volume":"32","author":"Vree","year":"1994","journal-title":"Int J Clin Pharmacol Ther"},{"key":"B30-20250823","doi-asserted-by":"crossref","first-page":"1716","DOI":"10.1097\/CCM.0000000000001002","article-title":"Extracorporeal treatment for metformin poisoning: Systematic review and recommendations from the extracorporeal treatments in poisoning workgroup","volume":"43","author":"Calello","year":"2015","journal-title":"Crit Care Med"},{"key":"B31-20250823","doi-asserted-by":"crossref","first-page":"c857","DOI":"10.1136\/bmj.c857","article-title":"Life threatening lactic acidosis","volume":"340","author":"Lemyze","year":"2010","journal-title":"BMJ"},{"key":"B32-20250823","doi-asserted-by":"crossref","first-page":"1265","DOI":"10.1097\/00000542-199905000-00007","article-title":"Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery","volume":"90","author":"Scheingraber","year":"1999","journal-title":"Anesthesiology"},{"key":"B33-20250823","doi-asserted-by":"crossref","first-page":"817","DOI":"10.1097\/00000539-200110000-00004","article-title":"Normal saline versus lactated Ringer\u2019s solution for intraoperative fluid management in patients undergoing abdominal aortic aneurysm repair: An outcome study","volume":"93","author":"Waters","year":"2001","journal-title":"Anesth Analg"},{"key":"B34-20250823","doi-asserted-by":"crossref","first-page":"747","DOI":"10.7150\/ijms.5868","article-title":"Why is saline so acidic (and does it really matter?)","volume":"10","author":"Reddi","year":"2013","journal-title":"Int J Med Sci"},{"key":"B35-20250823","doi-asserted-by":"crossref","first-page":"492","DOI":"10.7326\/0003-4819-112-7-492","article-title":"Bicarbonate does not improve hemodynamics in critically ill patients who have lactic acidosis. A prospective, controlled clinical study","volume":"112","author":"Cooper","year":"1990","journal-title":"Ann Intern Med"},{"key":"B36-20250823","doi-asserted-by":"crossref","first-page":"619","DOI":"10.1053\/j.jvca.2021.10.021","article-title":"Con: Metabolic acidosis should not be corrected with sodium bicarbonate in cardiac surgical patients","volume":"36","author":"Jia","year":"2022","journal-title":"J Cardiothorac Vasc Anesth"},{"key":"B37-20250823","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1097\/00000441-199602000-00001","article-title":"Effect of acute ketoacidosis on the myocardium in diabetes","volume":"311","author":"George","year":"1996","journal-title":"Am J Med Sci"},{"key":"B38-20250823","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1186\/2110-5820-1-23","article-title":"Bicarbonate in diabetic ketoacidosis: A systematic review","volume":"1","author":"Chua","year":"2011","journal-title":"Ann Intensive Care"},{"key":"B39-20250823","doi-asserted-by":"crossref","first-page":"167","DOI":"10.1016\/j.hrtlng.2019.10.007","article-title":"Bicarbonate use and mortality outcome among critically ill patients with metabolic acidosis: A meta analysis","volume":"49","author":"Lo","year":"2020","journal-title":"Heart Lung"},{"key":"B40-20250823","doi-asserted-by":"crossref","first-page":"528","DOI":"10.1097\/SHK.0000000000001415","article-title":"Lactic acidosis and the role of sodium bicarbonate: A narrative opinion","volume":"53","author":"Rudnick","year":"2020","journal-title":"Shock"},{"key":"B41-20250823","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1016\/S0140-6736(18)31080-8","article-title":"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","volume":"392","author":"Jaber","year":"2018","journal-title":"Lancet"},{"key":"B42-20250823","doi-asserted-by":"crossref","first-page":"e65283","DOI":"10.1371\/journal.pone.0065283","article-title":"Effect of sodium bicarbonate administration on mortality in patients with lactic acidosis: A retrospective analysis","volume":"8","author":"Kim","year":"2013","journal-title":"PLoS One"},{"key":"B43-20250823","doi-asserted-by":"crossref","first-page":"E1","DOI":"10.1002\/jhm.600","article-title":"Treatment of lactic acidosis: Appropriate confusion","volume":"5","author":"Rachoin","year":"2010","journal-title":"J Hosp Med"},{"key":"B44-20250823","doi-asserted-by":"crossref","first-page":"374","DOI":"10.1093\/ckj\/sfv045","article-title":"Lactate clearance and metabolic aspects of continuous high-volume hemofiltration","volume":"8","author":"Cheungpasitporn","year":"2015","journal-title":"Clin Kidney J"},{"key":"B45-20250823","doi-asserted-by":"crossref","first-page":"58","DOI":"10.1097\/00003246-199701000-00013","article-title":"Effect of continuous venovenous hemofiltration with dialysis on lactate clearance in critically ill patients","volume":"25","author":"Levraut","year":"1997","journal-title":"Crit Care Med"},{"key":"B46-20250823","first-page":"56","article-title":"Permissive hypercapnia: Role in protective lung ventilatory strategies","volume":"11","author":"Ni Chonghaile","year":"2005","journal-title":"Curr Opin Crit Care"},{"key":"B47-20250823","doi-asserted-by":"crossref","first-page":"223","DOI":"10.1097\/MNH.0000000000000687","article-title":"Sodium bicarbonate therapy for acute respiratory acidosis","volume":"30","author":"Chand","year":"2021","journal-title":"Curr Opin Nephrol Hypertens"},{"key":"B48-20250823","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1053\/j.ajkd.2019.05.029","article-title":"Alkali therapy for respiratory acidosis: A medical controversy","volume":"75","author":"Adrogu\u00e9","year":"2020","journal-title":"Am J Kidney Dis"},{"key":"B49-20250823","doi-asserted-by":"crossref","first-page":"222","DOI":"10.1186\/s12882-019-1378-y","article-title":"CO2 and O2 removal during continuous veno-venous hemofiltration: A pilot study","volume":"20","author":"Jonckheer","year":"2019","journal-title":"BMC Nephrol"},{"key":"B50-20250823","doi-asserted-by":"crossref","first-page":"517","DOI":"10.4187\/respcare.07290","article-title":"Extracorporeal carbon dioxide removal during continuous renal replacement therapy as adjunctive therapy","volume":"65","author":"Jacobs","year":"2020","journal-title":"Respir Care"},{"key":"B51-20250823","doi-asserted-by":"crossref","first-page":"R154","DOI":"10.1186\/cc12833","article-title":"Low-flow CO2 removal integrated into a renal-replacement circuit can reduce acidosis and decrease vasopressor requirements","volume":"17","author":"Forster","year":"2013","journal-title":"Crit Care"},{"key":"B52-20250823","doi-asserted-by":"crossref","first-page":"599","DOI":"10.1111\/aor.13393","article-title":"Rescue therapy for hypercapnia due to high PEEP mechanical ventilation in patients with ARDS and renal failure","volume":"43","author":"Grant","year":"2019","journal-title":"Artif Organs"},{"key":"B53-20250823","doi-asserted-by":"crossref","first-page":"420","DOI":"10.1186\/cc13802","article-title":"Metabolic alkalosis is the most common acid-base disorder in ICU patients","volume":"18","author":"Maehle","year":"2014","journal-title":"Crit Care"},{"key":"B54-20250823","doi-asserted-by":"crossref","first-page":"497","DOI":"10.1080\/10408369991239286","article-title":"Metabolic alkalosis in the critically ill","volume":"36","author":"Webster","year":"1999","journal-title":"Crit Rev Clin Lab Sci"},{"key":"B55-20250823","doi-asserted-by":"crossref","first-page":"1848","DOI":"10.2215\/CJN.16041219","article-title":"Metabolic alkalosis: A brief pathophysiologic review","volume":"15","author":"Emmett","year":"2020","journal-title":"Clin J Am Soc Nephrol"},{"key":"B56-20250823","doi-asserted-by":"crossref","first-page":"733","DOI":"10.1097\/00007611-197506000-00018","article-title":"Bicarbonate overshot\u201d: An indication for acetazolamide therapy","volume":"68","author":"Whang","year":"1975","journal-title":"South Med J"},{"key":"B57-20250823","first-page":"317","article-title":"Dynamic aspects of metabolic acid base disturbances: Phenformin lactic acidosis with alkaline overshoot","volume":"85","author":"Robin","year":"1972","journal-title":"Trans Assoc Am Physicians"},{"key":"B58-20250823","first-page":"6578","article-title":"Citrate metabolism in blood transfusions and its relationship due to metabolic alkalosis and respiratory acidosis","volume":"8","author":"Li","year":"2015","journal-title":"Int J Clin Exp Med"},{"key":"B59-20250823","doi-asserted-by":"crossref","first-page":"489","DOI":"10.1111\/sdi.12970","article-title":"Complications associated with continuous renal replacement therapy","volume":"34","author":"Kovvuru","year":"2021","journal-title":"Semin Dial"},{"key":"B60-20250823","doi-asserted-by":"crossref","first-page":"281","DOI":"10.1186\/s13054-017-1880-1","article-title":"Complications of regional citrate anticoagulation: Accumulation or overload?","volume":"21","author":"Schneider","year":"2017","journal-title":"Crit Care"},{"key":"B61-20250823","doi-asserted-by":"crossref","first-page":"437","DOI":"10.3109\/15412550903341448","article-title":"Post-hypercapnic alkalosis is associated with ventilator dependence and increased ICU stay","volume":"6","author":"Banga","year":"2009","journal-title":"COPD"},{"key":"B62-20250823","doi-asserted-by":"crossref","first-page":"729","DOI":"10.1097\/00007611-198706000-00016","article-title":"Alkalemia-associated morbidity and mortality in medical and surgical patients","volume":"80","author":"Anderson","year":"1987","journal-title":"South Med J"},{"key":"B63-20250823","doi-asserted-by":"crossref","first-page":"e0168563","DOI":"10.1371\/journal.pone.0168563","article-title":"Alkalosis in critically ill patients with severe sepsis and septic shock","volume":"12","author":"Kre\u00fc","year":"2017","journal-title":"PLoS One"},{"key":"B64-20250823","doi-asserted-by":"crossref","first-page":"140","DOI":"10.1056\/NEJM200201103460218","article-title":"Use of a proton-pump inhibitor for metabolic disturbances associated with anorexia nervosa","volume":"346","author":"Eiro","year":"2002","journal-title":"N Engl J Med"},{"key":"B65-20250823","first-page":"455","article-title":"Acetazolamide in the treatment of metabolic alkalosis in critically ill patients","volume":"20","author":"Marik","year":"1991","journal-title":"Heart Lung"},{"key":"B66-20250823","doi-asserted-by":"crossref","first-page":"522","DOI":"10.1177\/1060028018754389","article-title":"Hydrochloric acid infusion for the treatment of metabolic alkalosis in surgical intensive care unit patients","volume":"52","author":"Guffey","year":"2018","journal-title":"Ann Pharmacother"},{"key":"B67-20250823","doi-asserted-by":"crossref","first-page":"859","DOI":"10.1007\/s00134-010-1795-7","article-title":"Effectiveness of acetazolamide for reversal of metabolic alkalosis in weaning COPD patients from mechanical ventilation","volume":"36","author":"Faisy","year":"2010","journal-title":"Intensive Care Med"}],"container-title":["Clinical Journal of the American Society of Nephrology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ovid.com\/10.2215\/CJN.04500422","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T13:43:38Z","timestamp":1786369418000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ovid.com\/10.2215\/CJN.04500422"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,8,23]]},"references-count":65,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2023]]}},"URL":"https:\/\/doi.org\/10.2215\/cjn.04500422","relation":{},"ISSN":["1555-9041","1555-905X"],"issn-type":[{"value":"1555-9041","type":"print"},{"value":"1555-905X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,8,23]]}}}