A pH under 7.1 is an emergency, due to the risk of cardiac arrhythmias, and may warrant treatment with intravenous bicarbonate. Bicarbonate is given at 50-100 mmol at a time under scrupulous monitoring of the arterial blood gas readings. This intervention however, is not effective in case of lactic acidosis.
If the acidosis is particularly severe and/or there may be intoxication, consultation with the nephrology team is considered useful, as dialysis may clear both the intoxication and the acidosis.
Aim is to Maintain adequate tissue oxygenation & Hemodynamic stability.
Treatment of the cause should be our primary aim. Administration of bicarbonates and dialysis is required for metabolic acidosis that is associated with Renal failure.
Restoration of adequate intravascular volume and proper peripheral  perfusion is necessary for metabolic acidosis caused by lactic acidosis.
Administration of fomepizole or ethanol to inhibit alcohol dehydrogenase, a critical enzyme in metabolism of the alcohols, is beneficial in treatment of ethylene glycol and methanol intoxication and possibly diethylene glycol and propylene glycol intoxication.
Dialysis to remove the unmetabolized alcohol and possibly the organic acid anion can be helpful in treatment of several of the alcohol-related intoxications.
Simple to use bicarbonate
hypercapnia,
liver necrosis in newborns
Dialysis to remove the unmetabolized alcohol and possibly the organic acid anion can be helpful in the treatment of several of the alcohol-related intoxications
hypotension can occur during procedure
DKA is managed in an intensive care unit during the first day is always advisable
Fluid, Insulin and electrolyte replacement are most crucial for DKA management.
Correction of fluid loss with intravenous fluids only , Correction of hyperglycemia with insulin, Correction of electrolyte disturbances, particularly potassium loss is < 5.5, Correction of acid-base balance by bicarbonate if <7.1,  Treatment of concurrent infection by antibiotics, if present.
Add dextrose into 0.45% normal saline when serum glucose <200 mg/dl and sodium <135.
Switch to subcutaneous basal-bolus insulin for the following :
Overlap subcutaneous and IV insulin by 1-2 hours.
Hold insulin for serum potassium <3.3 mEq/L
Nearly all patients are potassium depleted, even with hyperkalemia
Monitor serum calcium frequently
Renal Tubular Acidosis
The treatment of type 1 and type 2 RTA is relatively simple.
Type 4 RTA may require treatment with fludrocortisone.
It requires the use of sodium bicarbonate or the slightly more palatable compound Shohl solution/Bicitra, which contains citric acid and sodium citrate as a source of alkali.
To reverse the hyperkalemia that characterizes the metabolic acidosis of type 4 RTA, dietary potassium restriction and orally administered potassium binders, Kalexate, Kionex, Lokelma, patiromer, sodium polystyrene sulfonate, sodium zirconium cyclosilicate may be needed.
Polycitra K solutions contain potassium citrate to provide equal amounts of alkali and potassium i-e  2 mEq/mL of alkali and 2 mEq/mL of potassium, to correct both the acidosis and hypokalemia
Finally, to increase renal excretion of potassium use diuretics like chlorothiazide, and furosemide may be required to correct hyperkalemia.
To neutralize the metabolic acidosis, bicarbonate therapy can also be used
Lactic Acidosis:
Treatment for Lactic Acidosis starts with Identification of the primary illness and correction of that disturbance.
Restoration of tissue oxygen delivery through hemodynamic and/or respiratory support is the key therapeutic goal in type A lactic acidosis.
The use of sodium bicarbonate in lactic acidosis is controversial, particularly in patients with circulatory and respiratory failure. Despite the controversy most physicians support administration of NaHCO3 for very severe acidemia and will give small amounts of NaHCO3 to maintain the arterial pH above 7.10.
Administration of Bicarbonates in a pH beyond 7.1 will promote the development of arrhythmias and cardiac depression.
Small animal studies of various models of shock and lactic acidosis demonstrated improved cardiac function, reduced mortality, and decreased generation of pro-inflammatory cytokines; human studies yet to be performed, so options include as follows:
Metabolic acidosis is considered an absolute contraindication to the use of the following<unk> ions:
Glyburide and Metformin
Saxagliptin hydrochloride and Metformin hydrochloride
Topiramate
Metabolic acidosis medical therapy
Metabolic alkalosis medical therapy
Respiratory acidosis medical therapy
Lactic acidosis medical therapy
Diabetic ketoacidosis medical therapy
Renal tubular acidosis medical therapy
Diabetic coma medical therapy
Metabolic alkalosis secondary prevention