›Hold or reduce diuretic dose
›Discontinue NG suction if clinically feasible
›Stop alkali-containing infusions (bicarbonate, acetate-based TPN, citrate)
›Reduce ongoing gastric acid losses
›Proton pump inhibitor (pantoprazole 40 mg IV daily) — reduces acid production if NG drainage must continue
›H2-blocker alternative — ranitidine (where available) or famotidine 20 mg IV bid
›Antiemetic therapy for ongoing vomiting
›Ondansetron 4–8 mg IV every 6–8 hours
›Metoclopramide 10 mg IV every 8 hours
Chloride-resistant metabolic alkalosis treatment
›Treat underlying cause — saline will not correct
›Primary hyperaldosteronism — spironolactone or adrenalectomy for unilateral adenoma
›Cushing syndrome — surgical resection or targeted therapy
›Renovascular hypertension — ACE inhibitor or revascularization
›Bartter syndrome — NSAIDs (indomethacin 2–3 mg/kg/day) or ACE inhibitors
›Gitelman syndrome — oral magnesium and potassium supplementation long-term
›Potassium-sparing diuretics
›Spironolactone 25–100 mg PO daily
›Particularly useful in mineralocorticoid excess or CHF
›Onset of action: 48–72 hours
›Amiloride 5–10 mg PO daily — alternative in patients intolerant to spironolactone
›Eplerenone 25–50 mg PO daily — selective aldosterone antagonist; less anti-androgenic side effects
›Acetazolamide in volume-overloaded patients
›Acetazolamide 250–375 mg IV or PO once or twice daily
›Promotes bicarbonaturia
›Preferred when saline is contraindicated (CHF, cirrhosis, ESRD)
›Monitor potassium closely — also promotes kaliuresis
›Avoid in sulfonamide allergy and severe hepatic encephalopathy
Refractory and life-threatening alkalosis treatment
›Hydrochloric acid infusion — reserved for pH > 7.60, refractory cases
›0.1–0.2 N HCl via central line only
›Calculate HCl dose: mEq HCl = 0.2 × body weight (kg) × (HCO3 – 24)
›Infuse no faster than 0.2 mmol/kg/hr
›Target reduction of HCO3 to < 40 mmol/l; recheck ABG every 4 hours
›Strict central line access — peripheral infusion causes severe tissue necrosis
›ACEP Level C recommendation; use with nephrology input
›Ammonium chloride 1.5–3.0 g IV over 2–3 hours — alternative acidifying agent
›Contraindicated in hepatic failure (ammonia toxicity)
›Arginine hydrochloride — historical alternative; also contraindicated in renal or hepatic failure
›Renal replacement therapy
›Hemodialysis with low-bicarbonate dialysate (25 mmol/l)
›Indication: concurrent renal failure or volume overload preventing saline therapy
›CRRT with NaCl replacement solution
›Indication: hemodynamically unstable patients
›CVVH or CVVHDF mode with low-bicarbonate replacement fluid
Special treatment scenarios
›CHF with metabolic alkalosis — high-risk combination
›Saline contraindicated — will precipitate pulmonary edema
›Acetazolamide 250–375 mg PO/IV once or twice daily as primary treatment
›Potassium-sparing diuretic addition (spironolactone or amiloride)
›Diuretic dose optimization rather than cessation
›Target dry weight reassessment with careful electrolyte monitoring
›Ventilator management in intubated patients
›Avoid inappropriate hyperventilation — do not suppress compensatory hypercapnia
›Target pH 7.35–7.45 and PaCO2 near expected compensation
›Permissive mild alkalemia may be acceptable if patient improving