A 2-year-old in the PICU has severe metabolic acidosis from septic shock: pH 7.12, HCO3 10 mEq/L, PaCO2 22 mmHg. Which condition is an indication for sodium bicarbonate therapy?
- A HCO3 <15 mEq/L regardless of clinical status
- B Base deficit >5 mEq/L in all cases of lactic acidosis
- C pH <7.20 with adequate ventilation and hemodynamic instability persisting despite fluids ✓
- D Hyperkalemia with peaked T waves
Correct answer: C. pH <7.20 with adequate ventilation and hemodynamic instability persisting despite fluids
Explanation
Bicarbonate therapy in metabolic acidosis is controversial and reserved for severe acidemia (pH <7.20) with hemodynamic compromise despite adequate resuscitation and ventilation. Routine use in lactic acidosis is not recommended as it may worsen intracellular acidosis and generate CO2. Bicarbonate does shift potassium intracellularly but specific therapy for hyperkalemia takes precedence. Overuse causes hypernatremia and paradoxical CSF acidosis.
Reference: Roguin's Pediatric Critical Care, 5th ed.
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