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Severe/Worsening I metabolic acidemia? I

Alkali administration to maintain blood pH > 7.20

• Continue therapy

• Manage predisposing conditions

Lactic acidosis management. Management of lactic acidosis should focus primarily on securing adequate tissue oxygenation and on aggressively identifying and treating the underlying cause or predisposing condition. Monitoring of the patient's hemodynamics, oxygenation, and acid-base status should be used to guide therapy. In the presence of severe or worsening metabolic acidemia, these measures should be supplemented by judicious administration of sodium bicarbonate, given as an infusion rather than a bolus. Alkali administration should be regarded as a temporizing maneuver adjunctive to cause-specific measures. Given the ominous prognosis of lactic acidosis, clinicians should strive to prevent its development by maintaining adequate fluid balance, optimizing cardiorespiratory function, managing infection, and using drugs that predispose to the disorder cautiously. Preventing the development of lactic acidosis is all the more important in patients at special risk for developing it, such as those with diabetes mellitus or advanced cardiac, respiratory, renal, or hepatic disease [1,14-16].

Diabetic ketoacidosis and nonketotic hyperglycemia

Cortisol Epinephrine

Increased ketogenesis

Increased ketogenesis

Increased gluconeogenesis Increased glycogenolysis Decreased glucose uptake

Increased gluconeogenesis Increased glycogenolysis Decreased glucose uptake ft

Increased protein breakdown

Cortisol Epinephrine

Counterregulation

r-^si Ketonemia V,

(metabolic acidosis)

Hyperglycemia (hyperosmolality)

Increased protein breakdown

Decreased amino acid uptake

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