Bicarbonate therapy for critically ill patients with metabolic acidosis

NEPHROLOGY AND HYPERTENSION;

HOSPITAL MEDICINE;

PULMONARY AND CRITICAL CARE MEDICINE;

EMERGENCY MEDICINE (ADULT AND PEDIATRIC) (June 2018)

​

Bicarbonate therapy for critically ill patients with metabolic acidosis

​

● In patients with acute metabolic acidosis, an arterial pH 7.1 to 7.2, and severe acute kidney injury, we suggest intravenous sodium bicarbonate therapy, rather than no alkali therapy (Grade 2B). We do not typically give sodium bicarbonate to patients with arterial pH 7.1 or higher if they do not have severe acute kidney injury.

​

While indications for bicarbonate therapy in metabolic acidosis are controversial, most experts treat patients who have acute metabolic acidosis and severe acidemia (ie, arterial pH <7.1) with bicarbonate therapy. There is less consensus about treatment of patients with less severe acidemia (eg, pH 7.1 to 7.2). A randomized trial assigned 389 critically ill patients with metabolic acidosis (mean serum bicarbonate, 13 mmol/L, and most with elevated lactate levels) and acidemia (arterial pH ≤7.2, mean 7.15) to either intravenous infusions of sodium bicarbonate to maintain a pH >7.3 or to no sodium bicarbonate. Bicarbonate therapy had no overall effect on mortality at 28 days or organ failure at seven days, although there was a trend toward improved outcomes in the bicarbonate group. However, among the subgroup of patients with severe acute kidney injury (defined as a twofold or greater increase in serum creatinine or oliguria), bicarbonate therapy reduced 28-day mortality (46 versus 63 percent) and the need for dialysis (51 versus 73 percent). For patients with acute metabolic acidosis and an arterial pH 7.1 to 7.2, UpToDate suggests bicarbonate therapy when severe acute kidney injury is also present.

​

REF. UpToDate 2019.07.06