Sudden cardiac failure following treatment of metabolic alkalosis with hydrochloric acid

Introduction

Severe metabolic alkalosis is a common problem in ICU due to high gastric reflux, diuretic drugs or parenteral nutrition. The mortality is considerable. Therapy of severe metabolic alkalosis with hydrochloric acid is widely accepted and described as save and effective.

Patients

We report five unexplained cases of acute cardiac arrest on our ICU in 1998 following infusion of hydrochloric acid in mechanically ventilated patients with severe metabolic alkalosis. Treatment with HCl (0.2 N, 10–15 ml/h) was commenced at pH 7.55 and BE +10 mmol/l. All patients suddenly showed a marked fall of oxygen saturation followed by bradycardia, hypotension and cardiac arrest 30 to 140 min after onset of HCl -infusion. CPR and high dose adrenalin (up to 5 mg in bolus) showed no effect. Oxygenation could not be improved by FiO₂ 1.0. No patient survived the incident. The clinical aspect suggested a fulminant pulmonary embolism as the most likely cause of death. Autopsy was performed in three patients. The cause of death remains unclear. A fulminant pulmonary embolism could be excluded in these patients.

Conclusions

The therapy of severe metabolic alkalosis with HCl is suggested to be linked with potentially lethal complications. The observed and reported cases of death should he considered before application of HCl in treatment of severe metabolic alkalosis. Further studies are requested to analyze the reasons for sudden cardiac failure during HCl-infusion.

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