In a shocked patient with a low pH, the acidosis is usually a marker of hypoperfusion, sepsis, ischaemia or toxins. The treatment that corrects it is restoring perfusion and removing the cause: fluids, vasopressors, source control, and dialysis where indicated. Check lactate, anion gap, glucose, ketones, kidney function and a toxicology history. Bicarbonate still has specific uses — severe hyperkalaemia, tricyclic antidepressant or other sodium-channel blocker toxicity, and bicarbonate-losing states such as severe diarrhoea — so name the reason whenever you prescribe it.
- Work out why the patient is acidotic before treating the number.
- Calculate the anion gap and check lactate, ketones and kidney function.
- Reserve bicarbonate for specific indications such as sodium-channel blocker toxicity or severe hyperkalaemia.
- Document the indication whenever bicarbonate is given.
Why it matters
A normal pH achieved with bicarbonate can hide a cause that is still unfixed.
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