The primary treatment of acidosis in shock is to reverse the underlying cause. Because this goal is not rapidly attainable, intravenous bicarbonate is often administered. The rationale for giving bicarbonate is that it will diminish myocardial depression and counteract the insensitivity to endogenous catecholamines attributed to acidosis, but experimental data indicate that exogenous bicarbonate can actually worsen intracellular acidosis, and prospective studies have not shown benefit.21 Bicarbonate also shifts the oxygen-hemoglobin dissociation curve to the left and impairs tissue unloading of hemoglobin-bound oxygen. However, many clinicians remain uncomfortable withholding bicarbonate, which has created disparate opinions in the medical literature. 22 A middle ground to correct the metabolic acidosis partially over time is as follows: calculate the bicarbonate deficit, which is equal to (normal HCO 3- minus the patient's HCO3-) * 0.4 * body weight (kilograms), with one-half of this amount infused slowly and the remainder over 6 to 8 h to a pH of no greater than 7.25.
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