Less renal replacement therapy with sodium bicarbonate infusion for patients with severe metabolic acidosis

Reference

Jaber S, Paugam C, Futier E, et al, for the BICAR-ICU Study Group. Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomized controlled, phase 3 trial. Lancet 2018;392:31-40.

Synopsis

These investigators randomized 389 critically ill patients with severe metabolic acidosis (pH < 7.20, PaCO2 < 45 mmHg, and sodium bicarbonate < 20 mmol/L) to receive sodium bicarbonate (intervention group) or no sodium bicarbonate (control group). Main exclusion criteria included the presence of respiratory acidosis, evidence of gastrointestinal or urinary losses of sodium bicarbonate, stage IV chronic kidney disease, and ketoacidosis. Baseline characteristics were similar in the 2 groups. The intervention group received 4.2% sodium bicarbonate intravenously at a volume of 125 mL to 250 mL per infusion to target an arterial pH of 7.30. The 2 groups were otherwise treated similarly. More than half the patients had acidemia related to septic shock and approximately 80% were receiving mechanical ventilation and vasopressor support. One quarter of the patients in the control group did receive sodium bicarbonate during the course of the study, primarily as a salvage therapy. Although there was no significant difference detected in the primary composite outcome of 28-day all-cause death or organ failure at 7 days (66% in intervention group vs 71% in control group; P = .24), the intervention group did have fewer patients who required renal replacement therapy (35% vs 52%; P = .0009). Additionally, in the subgroup of patients with acute kidney injury, the intervention group fared better with fewer deaths (number needed to treat = 6), less organ failure, and increased number of vasopressor-free days.