In this episode, I’ll discuss sodium bicarbonate for critically ill adult patients with metabolic acidosis and shock.
The tale as old as time with sodium bicarbonate is that while it corrects plasma pH in critically ill patients with metabolic acidosis, whether clinically meaningful outcomes are improved remains uncertain.
To investigate this issue, a group of authors has published in New England Journal of Medicine the results of a multi-center randomized trial looking at sodium bicarbonate vs placebo in adult patients with metabolic acidosis who were receiving vasopressors in the intensive care unit.
Sodium bicarbonate or 5% dextrose was given to 500 patients across 55 ICUs. The primary outcome was a major adverse kidney event, defined as death, use of renal-replacement therapy, or persistent renal dysfunction, within 30 days. A major adverse kidney event within 30 days occurred in 40.2% of the sodium bicarbonate group and in 39.4% of the placebo group, a difference that was not statistically significant. Likewise, the difference in in-hospital mortality by day 30 was 25.4% in the sodium bicarbonate group and 24.0% in the placebo group, also not significant. There was also no significant difference in the rate of renal replacement therapy between groups.
The authors concluded:
The use of sodium bicarbonate in critically ill patients with metabolic acidosis receiving vasopressors did not lead to a lower risk of major adverse kidney events within 30 days than placebo.
The dose of bicarb used in the study was a 500 mL bag of D5W with 300 mL removed and replaced with 300 mL of sodium bicarbonate 8.4% for a final concentration of 600 mEq/L. The infusion started at 100 mL/hr until pH and base excess targets were met and was then decreased to 25 mL/hr and shut off after a maximum of 5 hours. This method of an infusion limited to 5-hours only does not mirror all practices and may leave some doubt in clinicians’ minds as to whether further study might be warranted before abandoning this approach in critically ill hemodynamically unstable patients with metabolic acidosis.
The article in this episode is a selection from my Hospital Pharmacy Academy’s weekly literature digest. Have you ever felt like your physician colleagues are one step ahead of you with new literature developments? Every week, Academy members are provided a summary curated and explained by me of the top hospital pharmacy-related articles published that week from over 20 major journals and sources to save you time and keep you up to date with the literature. To get immediate access, go to pharmacyjoe.com/academy.
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