The goal of intensivists is to restore all of a patient’s physiologic balances as soon as possible, generally by seeking and treating the cause(s) of any alteration. However, even though acute metabolic acidosis is common among critically ill patients, its mechanisms are complex, making it difficult to identify the cause. Consequently, attention often shifts from treatment of the cause to correction of the pH.

Acidemia is defined as pH less than 7.38, and severe acidemia as pH of 7.20 or lower. The combination of low pH with a plasma bicarbonate concentration less than 20 mM defines metabolic acidosis, which is one of the most frequent acid–base disorders occurring in intensive care unit (ICU) patients, with an incidence ranging from 14 to 42%.2,3  In contrast, acute severe metabolic acidemia—when plasma pH is lower than...

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