Effect of bicarbonate administration on skeletal muscle intracellular pH in the rat: implications for acute administration of bicarbonate in man

[Diabetic ketoacidosis in adults--update of an old complication]

Diabetic ketoacidosis is an acute complication of Diabetes Mellitus characterized by hyperglycemia, metabolic acidosis, dehydration, and ketosis, in patients with profound insulin deficiency. It occurs predominantly in patients with type 1 diabetes and is frequently precipitated by infections, insulin withdrawal or undiagnosed type 1 diabetes. The authors review its pathophysiology, diagnostic criteria and treatment options in adults, as well as its complications.

Dichloroacetate stabilizes the intraoperative acid-base balance during liver transplantation

Lactic acidosis occurs during orthotopic liver transplantation (OLT), especially during the anhepatic and early postreperfusion phases. Dichloroacetate (DCA) inhibits pyruvate dehydrogenase kinase-1, indirectly activating mitochondrial pyruvate dehydrogenase. This, in turn, markedly reduces systemic lactate production and, to a lesser extent, increases hepatic lactate uptake. The result is moderation of lactic acidosis in many clinical conditions. This study evaluated the efficacy of DCA in controlling lactic acidosis during OLT and improving perioperative outcome from OLT. After informed consent, 250 patients for OLT received either intraoperative DCA or placebo. DCA (40 mg/kg intravenously) or placebo was administered after anesthesia induction and repeated 4 hours later. Intraoperative measures were arterial blood gases, lactate, and Na+ and utilization of blood products, CaCl2, and NaHCO3. Outcome measures were time to tracheal extubation, intensive care unit length of stay, hospital length of stay, requirement for postoperative plasma transfusion, retransplantation, and perioperative mortality. DCA reduced the arterial lactic acid concentration by an average of 44% (1.8 mmol L(-1), P < 0.001), stabilized the acid-base balance, and reduced NaHCO(3) administration by 80% (P < 0.001). Postoperatively, DCA-treated patients required 50% less postoperative plasma transfusion (2 versus 4 units, respectively, P = 0.016), but the incidence of transfusion was similar in both groups (62% versus 60%, P = 0.381). DCA did not alter time to extubation, intensive care unit length of stay, or hospital length of stay. In conclusion, DCA attenuated lactic acidosis during OLT, stabilizing the intraoperative acid-base balance and decreasing NaHCO3 use. DCA decreased postoperative plasma transfusion requirement but otherwise had no measurable effect on perioperative outcome parameters.

Preexercise metabolic alkalosis induced via bicarbonate ingestion accelerates V̇o2 kinetics at the onset of a high-power-output exercise in humans

The present study investigated the effect of preexercise metabolic alkalosis on the primary component of oxygen uptake (V̇o2) kinetics, characterized by τ1. Seven healthy physically active nonsmoking men, aged 22.4 ± 1.8 (mean ± SD) yr, maximum V̇o2 (V̇o2 max) 50.4 ± 4 ml·min−1·kg−1, performed two bouts of cycling, corresponding to 40 and 87% of V̇o2 max, lasting 6 min each, separated by a 20-min pause, once as a control study and a few days later at ∼90 min after ingestion of 3 mmol/kg body wt of NaHCO3. Blood samples for measurements of bicarbonate concentration and hydrogen ion concentration were taken from antecubital vein via catheter. Pulmonary V̇o2 was measured continuously breath by breath. The values of τ1 were calculated by using six various approaches published in the literature. Preexercise level of bicarbonate concentration after ingestion of NaHCO3 was significantly elevated ( P < 0.01) compared with the control study (28.96 ± 2.11 vs. 24.84 ± 1.18 mmol/l; P < 0.01), and [H+] was significantly ( P < 0.01) reduced (42.79 ± 3.38 nmol/l vs. 46.44 ± 3.51 nmol/l). This shift ( P < 0.01) was also present during both bouts of exercise. During cycling at 40% of V̇o2 max, no significant effect of the preexercise alkalosis on the magnitude of τ1 was found. However, during cycling at 87% of V̇o2 max, the τ1 calculated by all six approaches was significantly ( P < 0.05) reduced, compared with the control study. The τ1 calculated as in Borrani et al. (Borrani F, Candau R, Millet GY, Perrey S, Fuchsloscher J, and Rouillon JD. J Appl Physiol 90: 2212–2220, 2001) was reduced on average by 7.9 ± 2.6 s, which was significantly different from zero with both the Student's t-test ( P = 0.011) and the Wilcoxon's signed-ranks test ( P = 0.014).

Hyperglycaemic crises and lactic acidosis in diabetes mellitus

Diabetic ketoacidosis, hyperglycaemic hyperosmolar state, and lactic acidosis represent three of the most serious acute complications of diabetes. There have been some advances in our understanding of the pathogenesis of these conditions over the last three decades, together with more uniform agreement on their treatment and innovations in technology. Accordingly their incidence, morbidity, and mortality are decreasing, but at rates that fall short of our aspirations. Hyperglycaemic crises in particular remain an important cause of morbidity and mortality in diabetic populations around the world. In this article, understanding of these conditions and advances in their management, and the available guidelines for their treatment, are reviewed. As far as is possible, the recommendations are based on clear published evidence; failing that, what is considered to be a common sense synthesis of consensus guidelines and recommendations is provided.

Sodium bicarbonate for the treatment of lactic acidosis

Lactic acidosis often challenges the intensivist and is associated with a strikingly high mortality. Treatment involves discerning and correcting its underlying cause, ensuring adequate oxygen delivery to tissues, reducing oxygen demand through sedation and mechanical ventilation, and (most controversially) attempting to alkalinize the blood with IV sodium bicarbonate. Here we review the literature to answer the following questions: Is a low pH bad? Can sodium bicarbonate raise the pH in vivo? Does increasing the blood pH with sodium bicarbonate have any salutary effects? Does sodium bicarbonate have negative side effects? We find that the oft-cited rationale for bicarbonate use, that it might ameliorate the hemodynamic depression of metabolic acidemia, has been disproved convincingly. Further, given the lack of evidence supporting its use, we cannot condone bicarbonate administration for patients with lactic acidosis, regardless of the degree of acidemia.

The effects of sodium bicarbonate and a mixture of sodium bicarbonate and carbonate ("Carbicarb") on skeletal muscle pH and hemodynamic status in rats with hypovolemic shock

Rats rendered hypotensive and acidotic by withdrawal of blood were treated by infusion of either an equimolar mixture of sodium bicarbonate and sodium carbonate ("Carbicarb"), sodium bicarbonate alone, or sodium chloride. Skeletal muscle intracellular pH (pHi) was measured using magnetic resonance spectroscopy from the chemical shift of the carbon-2 (C2) proton resonance of the imidazole ring of anserine. In the groups treated with alkali, arterial blood pH (pHa) was restored to normal, but no change was observed in the sodium chloride-treated animals. Despite an elevation of arterial blood partial pressure of CO2 (PaCO2) in the group treated with sodium bicarbonate, no significant change in pHi was observed in any group. Blood lactate levels, initially elevated in all groups, underwent only minor changes. In all three groups a transient and similar elevation of arterial blood pressure was observed after infusion. Differential effects of Carbicarb and sodium bicarbonate in metabolic acidosis may be dependent on the model of metabolic acidosis used, and an alteration in PaCO2 induced by alkali therapy may not be a major determinant of changes in pHi.