Sodium Bicarbonate Therapy for Patients with Severe Metabolic Acidaemia in the Intensive Care Unit (BICAR-ICU): A Multicentre, Open-Label, Randomised Controlled, Phase 3 Trial

Jaber S, Paugam C, Futier E, et al. Lancet. 2018 Jun 14. pii: S0140-6736(18)31080-8. [CrossRef] [PubMed]

Acute acidemia is frequently observed during critical illness. Sodium bicarbonate (bicarb) infusion for the treatment of severe metabolic acidemia is a possible treatment option but remains controversial and is not routinely recommended after cardiac arrest. The authors performed a multicenter, open-label, randomized controlled, phase 3 trial of bicarb in adult patients with severe acidemia (pH ≤7.20, PaCO2 ≤45 mm Hg) and with a total Sequential Organ Failure Assessment score of 4 or more or an arterial lactate concentration of 2 mmol/L or more. The primary outcome was a composite of death from any cause by day 28 and the presence of at least one organ failure at day 7. Death occurred in 138 (71%) of 194 patients in the control group and 128 (66%) of 195 in the bicarbonate group (p=0.24). However, in an a-priori defined group of patients with acute kidney injury the Kaplan-Meier method estimate of survival by day 28 between the control group and bicarbonate group was significantly improved (63% vs 46%; p=0.0283). The authors conclude that in patients with severe metabolic acidemia, sodium bicarbonate had no effect on mortality but improved the day 28 mortality in patients with acute kidney injury.