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Acetazolamide therapy for metabolic alkalosis in critically ill pediatric patients
Amir Bar1, Jeff Cies, Kathleen Stapleton
11Section of Pediatric Critical Care Medicine, Drexel University College of Medicine/St. Christopher's Hospital for Children, Philadelphia, PA. 2Department of Pathology and Laboratory Medicine, Drexel University College of Medicine/St. Christopher's Hospital for Children, Philadelphia, PA. 3Sleep Disorders Center, Drexel University College of Medicine/St. Christopher's Hospital for Children, Philadelphia, PA. 4Division of Pediatric Critical Care Medicine, New York University Langone Medical Center, New York, NY. 5Department of Pediatrics, New York University School of Medicine, New York, NY.
Insights
Acetazolamide effectively reduced plasma bicarbonate in critically ill children with metabolic alkalosis. However, it was not effective in pediatric cardiac patients, suggesting caution in their treatment.
Area of Science:
- Pediatric Critical Care Medicine
- Pediatric Pharmacology
- Pediatric Nephrology
Background:
- Acetazolamide is frequently used for metabolic alkalosis in critically ill children, despite limited evidence.
- Metabolic alkalosis is characterized by elevated plasma bicarbonate (pHco-3) and pH.
Purpose of the Study:
- To evaluate the efficacy of acetazolamide in reducing plasma bicarbonate levels in critically ill, mechanically ventilated children.
- To compare the response to acetazolamide between pediatric cardiac and noncardiac patients.
Main Methods:
- Retrospective study conducted in a pediatric intensive care unit (PICU).
- Included mechanically ventilated children aged 17 years or younger with metabolic alkalosis (pHco-3 ≥ 35 mmol/L).
- Assessed changes in pHco-3 levels 18 hours after initiating acetazolamide therapy.
Main Results:
- Overall, acetazolamide reduced pHco-3 in the cohort (40.2 to 36.2 mmol/L; p < 0.001).
- Noncardiac patients showed a significant reduction in pHco-3.
- Cardiac patients, including those younger than 6 months, did not show a significant change in pHco-3.
- Partial pressure of carbon dioxide (PCO2) remained unchanged in both subgroups.
Conclusions:
- Acetazolamide effectively lowers plasma bicarbonate in critically ill children overall.
- The drug's efficacy was not observed in pediatric cardiac patients within this cohort.
- Findings question the routine use of acetazolamide for metabolic alkalosis in critically ill children with congenital heart disease.
- Further research is needed to understand differential responses and clinical outcomes.
Objective:
Despite a paucity of supporting literature, acetazolamide is commonly used in critically ill children with metabolic alkalosis (elevated plasma bicarbonate [pHco-3] and pH). The objective of this study was to assess the change in 18 hours after initiation of acetazolamide therapy.
Design:
Retrospective study.
Setting:
PICU of an urban, tertiary-care children's hospital.
Patients:
Mechanically ventilated children (≤ 17 yr) with metabolic alkalosis (pHco-3 ≥ 35 mmol/L).
Interventions:
None.
Measurements And Main Results:
Of 153 consecutively screened patients, 61 patients (29 female patients) were enrolled: 18 cardiac patients (after congenital heart disease repair) and 43 noncardiac patients. The cardiac patients were younger than the noncardiac patients (median [interquartile range] age, 0.6 mo [0.3-2.5 mo] vs 7.4 mo [2.8-39.9 mo]; p < 0.00001) and had higher preacetazolamide baseline diuretic scores and urine output. The pHco-3 levels 18 hours after initiation of acetazolamide were reduced in the cohort as a whole (40.2 ± 4.8 to 36.2 ± 5.6 mmol/L; p < 0.001) and in the noncardiac patients, but they were unchanged in the cardiac patients. The PCO2 remained unchanged after acetazolamide in both subgroups. Because young age and presence of cardiac disease were potential confounders, the 20 noncardiac patients who are 6 months old or younger were compared with the cardiac subgroup and demonstrated reduced pHco-3 after acetazolamide and lower preacetazolamide baseline diuretic score and urine output.
Conclusion:
Acetazolamide reduces pHco-3 concentration in critically ill, mechanically ventilated children overall, but it did not do so in cardiac patients in our cohort, even in comparison with noncardiac patients of a similar age. These findings do not support the current use of acetazolamide for metabolic alkalosis in critically ill children with congenital heart disease. Further study is required to determine why these cardiac patients respond differently to acetazolamide than noncardiac patients and whether this response impacts important clinical outcomes, for example, weaning mechanical ventilation.
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