Work

Severe Metabolic Acidosis in the ICU

Year: 2026

Type: article

Abstract: Severe acidemia (pH < 7.20) involving metabolic acidosis affects 2% to 10% of patients in the ICU and is associated with high mortality rates. This condition can arise from various clinical contexts and often accompanies organ dysfunction, particularly cardiovascular impairment. Although addressing the underlying cause is crucial, the role of adjunctive interventions like buffer therapy or renal replacement therapy (RRT) remains debated. This article presents a clinical case to illustrate the diagnostic workup and provides an evidence-based update on current management strategies. It discusses phenotyping metabolic acidosis, consequences of severe metabolic acidemia, and available therapeutic strategies in the ICU. Buffers to mitigate acidemia in certain patients and the pros and cons of sodium bicarbonate (HCO 3 − ) infusion vs RRT are considered. A tailored approach, considering sodium HCO 3 − use to raise and maintain blood pH to > 7.20 in some patients, potentially delaying or avoiding RRT, may be useful. However, the optimal dose and duration of sodium HCO 3 − infusion remain unestablished, and further research is needed to refine decision-making processes in managing severe metabolic acidosis.

Source: CHEST Critical Care

DOI: 10.1016/j.chstcc.2026.100271

Authors: Boris Jung, Maxime Fosset, Tomoko Fujii, Jeffrey A. Kraut, Samir Jaber