Post-Hypercapnic Alkalosis: A Brief Review

Abstract

Metabolic alkalosis is a common acid-base imbalance frequently observed in intensive care unit (ICU) patients and is associated with increased mortality. Post-hypercarbia alkalosis (PHA) is a type of metabolic alkalosis caused by sustained high serum bicarbonate levels following a rapid resolution of hypoventilation in patients with chronic hypercapnia due to prolonged respiratory disturbance. Common causes of chronic hypercapnia include chronic obstructive pulmonary disease (COPD), central nervous system disorders, neuromuscular disorders, and narcotic abuse. Rapid correction of hypercapnia through hyperventilation leads to a swift normalization of pCO 2 , which lacks renal compensation, consequently causing an increase in plasma HCO 3- levels and severe metabolic alkalosis. Most of PHA occurs in the ICU setting requiring mechanical ventilation and can progress severe alkalemia due to secondary mineralocorticoid excess from volume depletion or decreased HCO 3- excretion from decreased glomerular filtration rate and increased proximal tubular reabsorption. PHA is associated with increased ICU stay, ventilator dependency, and mortality. Acetazolamide, a carbonic anhydrase inhibitor, has been utilized for managing PHA by inducing alkaline diuresis and reducing tubular reabsorption of bicarbonate. While acetazolamide effectively improves alkalemia, its impact on hard outcomes may be limited by factors such as patient complexity, co-administered medications, and underlying conditions contributing to alkalosis.

Profiling endogenous adrenal function during veno-venous ECMO support in COVID-19 ARDS: a descriptive analysis

“…Alkalosis is a reported complication of ECMO ( 21 ). Thus, base excess levels are also likely to be initially elevated in a manner of post-hypercapnic alkalosis ( 22 ). However, to our knowledge, this is the first report that relates post-hypercapnic alkalosis to the HPA stress response after ECMO initiation.…”

Mechanisms and physiological relevance of acid-base exchange in functional units of the kidney

“…Patients with mixed or type 2 respiratory failure often develop metabolic alkalosis, with increased bicarbonate levels compensating for the rise in blood CO 2 . Such post-hypercapnic alkalosis interferes with the respiratory function recovery via autonomic circuits ( Yi, 2023 ). Acetazolamide, a carbonic anhydrase inhibitor with mild diuretic effect, increases the rates of bicarbonate excretion with urine, thereby alleviating the systemic alkalosis ( Gulsvik et al, 2013 ).…”