Andrade Olberes V B, Ihara Flávio O, Troster Eduardo J
Faculdade de Ciências Médicas, Irmandade da Santa Casa de Misercordia de Sao Paulo, São Paulo, SP, Brazil.
J Pediatr (Rio J). 2007 May;83(2 Suppl):S11-21. doi: 10.2223/JPED.1616. Epub 2007 May 15.
To critically discuss the treatment of metabolic acidosis and the main mechanisms of disease associated with this disorder; and to describe controversial aspects related to the risks and benefits of using sodium bicarbonate and other therapies.
Review of PubMed/MEDLINE, LILACS and Cochrane Library databases for articles published between 1996 and 2006 using the following keywords: metabolic acidosis, lactic acidosis, ketoacidosis, diabetic ketoacidosis, cardiopulmonary resuscitation, sodium bicarbonate, treatment. Classical publications concerning the topic were also reviewed. The most recent and representative were selected, with emphasis on consensus statements and guidelines.
There is no evidence of benefits resulting from the use of sodium bicarbonate for the hemodynamic status, clinical outcome, morbidity and mortality in high anion gap metabolic acidosis associated with lactic acidosis, diabetic ketoacidosis and cardiopulmonary resuscitation. Therefore, the routine use of sodium bicarbonate is not indicated. Potential side effects must be taken into consideration. Treating the underlying disease is essential to reverse the process. The efficacy of other alternative therapies has not been demonstrated in large-scale studies.
Despite the known effects of acidemia on the organism in critical situations, a protective role of acidemia in hypoxic cells and the risk of alkalemia secondary to drug interventions are being considered. There is consensus regarding the advantages of alkali and sodium bicarbonate therapy in cases with normal anion gap; however, in the presence of high anion gap acidosis, especially lactic acidosis, diabetic acidosis and cardiopulmonary resuscitation, the use of sodium bicarbonate is not beneficial and has potential adverse effects, limiting its indication. The only points of agreement in the literature refer to the early treatment of the underlying disease and the mechanisms generating metabolic acidemia. Other promising treatment alternatives have been proposed; however, the side effects and absence of controlled studies with pediatric populations translate into lack of evidence to support the routine use of such treatments.
批判性地讨论代谢性酸中毒的治疗方法以及与此病症相关的主要发病机制；并描述与使用碳酸氢钠及其他治疗方法的风险和益处相关的争议性方面。
检索PubMed/MEDLINE、LILACS和Cochrane图书馆数据库，查找1996年至2006年间发表的文章，使用以下关键词：代谢性酸中毒、乳酸酸中毒、酮症酸中毒、糖尿病酮症酸中毒、心肺复苏、碳酸氢钠、治疗。还查阅了有关该主题的经典出版物。挑选了最新且具代表性的文献，重点关注共识声明和指南。
对于与乳酸酸中毒、糖尿病酮症酸中毒和心肺复苏相关的高阴离子间隙代谢性酸中毒，使用碳酸氢钠对血流动力学状态、临床结局、发病率和死亡率并无益处。因此，不建议常规使用碳酸氢钠。必须考虑潜在的副作用。治疗基础疾病对于逆转病情至关重要。其他替代疗法的疗效尚未在大规模研究中得到证实。
尽管已知酸血症在危急情况下对机体有影响，但酸血症在缺氧细胞中的保护作用以及药物干预继发碱血症的风险也受到关注。对于正常阴离子间隙的病例，碱和碳酸氢钠治疗的优势已达成共识；然而，在存在高阴离子间隙酸中毒，尤其是乳酸酸中毒、糖尿病酸中毒和心肺复苏时，使用碳酸氢钠并无益处且有潜在不良反应，限制了其应用指征。文献中唯一达成共识的要点是基础疾病的早期治疗以及产生代谢性酸血症的机制。已提出其他有前景的治疗替代方案；然而，副作用以及缺乏针对儿科人群的对照研究导致缺乏证据支持此类治疗的常规使用。
