Reversing acidaemia in critically unwell patients with bicarbonate

Metabolic acidaemia is frequently encountered among patients in the Intensive Care Unit (ICU). Administration of sodium bicarbonate infusions to manage this derangement remains an area of contention and varied practice given the lack of clinical outcomes data. Jaber et al (The Lancet 2018;392:31) performed an open­ label, randomised, controlled trial (RCT) across 26 French ICUs, which included a total of 389 patients. Their cohort had metabolic acidaemia defined as arterial blood gas (ABG) pH levels ≤7·20, PaCO₂ ≤45 mmHg and sodium bicarbonate concentration ≤20 mmol/L in addition to either Sequential Organ Failure Assessment (SOFA) score ≥4 or Lactate ≥2 mmol/L. The intervention arm received infusions of 4·2% sodium bicarbonate in order to increase and maintain arterial pH ≥7·30. The primary outcome was a composite of both 28 day mortality and the presence of at least one organ failure at day 7. They found no difference in the primary outcome, which was reached by 66% of the bicarbonate group and 71% in the control group (P=0.24). Of the secondary outcomes, bicarbonate reduced the necessity for renal replacement therapy from 52% to 35% (P=0.0009) and in patients with evidence …