Management of Severe Metabolic Alkalosis

Initial Assessment and Stabilization

Secure airway, breathing, and circulation as needed for critically ill presentation, and obtain immediate laboratory studies including complete electrolyte panel, arterial blood gas, and renal function tests, according to the Society of Critical Care Medicine 1
The European Society of Intensive Care Medicine recommends obtaining immediate laboratory studies including complete electrolyte panel, particularly potassium, chloride, bicarbonate, and arterial blood gas if not already available 1

Administer IV fluid boluses based on hemodynamic status and evidence of volume depletion, and continue with maintenance fluids to restore intravascular volume, as suggested by the European Society of Intensive Care Medicine 1
Target serum potassium >3.5 mEq/L, and monitor cardiac rhythm during rapid potassium replacement, according to the American Heart Association 1

The American College of Cardiology recommends continuous cardiac monitoring for arrhythmias, and serial blood gas measurements every 2-4 hours until pH <7.55, as stated by the American Diabetes Association 2
Monitor for signs of fluid overload during aggressive hydration, especially in patients with cardiac or renal dysfunction, as advised by the European Society of Intensive Care Medicine 1