A 70-year-old woman is admitted to the intensive care unit (ICU) with a pH of 7.1, an acute kidney injury (AKI), and ketonuria. She is volume depleted and her history is consistent with starvation ketosis. This LOL truly is in NAD (that's little old lady in no acute distress, for those who haven't read The House of God). She is clinically stable and seemingly unperturbed by the flurry of activity surrounding her admission.
Your resident is concerned by the severity of the acidosis and suggests starting an intravenous (IV) bicarbonate drip. The fellow is adamantly against it. He's been taught that IV bicarbonate increases the serum pH but paradoxically causes intracellular acidosis. As the attending you elect to observe fellow autonomy — no bicarb is given. Because any debate on rounds is a "teachable moment," you decide to review the evidence and physiology behind infusing bicarbonate.
What Do the Data Reveal?
An excellent review published in CHEST in 2000 covers the physiologic effects of bicarbonate, specifically related to lactic acidosis, which our patient didn't have. Aside from that difference, the review validates the fellow's opinion. In short, the authors state that a low pH may be a marker of a dangerous systemic condition, but it need not be corrected for its own sake.
