When, if ever, should we be giving bicarbonate in patients with metabolic acidosis?

A study published in The Lancet in July 2018 involved a multicentre RCT in 26 ICUs with 400 patients, called the BICAR-ICU trial. It found that in severe acidemia (<7.2), sodium bicarbonate infusion compared with no infusion did not decrease mortality over 28 days or decrease organ failure in 7 days in the overall population. However, it did find that in those patients with acute kidney injury, sodium bicarbonate infusion did reduce mortality over 28 days with overall those patients having fewer vasopressor-free days and more renal-replacement therapy-free days, meaning fewer days of hemodialysis or peritoneal dialysis.

Are there side effects with giving NaHCO3 infusions? Some patients developed hypernatremia, hypocalcemia, and metabolic alkalosis, but none of these were life-threatening.

Overall, it might be worth considering in your acidotic patients with AKI in order to potentially help them live longer and be less likely to be on dialysis. Central lines including Shileys and being hooked up to a large dialysis machine can’t be fun. In other patients, you might just be treating numbers.