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In this episode, episode 98, I discuss the BICAR-ICU trial and what it tells us about using sodium bicarbonate to treat metabolic acidosis.
CME: https://earnc.me/6uMndk
References:
BICAR-ICU Trial: https://www.ncbi.nlm.nih.gov/pubmed/29910040
BICAR-ICU Editorial: https://www.ncbi.nlm.nih.gov/pubmed/29910039
Forsythe: https://www.ncbi.nlm.nih.gov/pubmed/10631227
Sabatini: https://www.ncbi.nlm.nih.gov/pubmed/18322160
Pulmcrit post: https://emcrit.org/pulmcrit/bicar-icu/
What do you think about a bicarbonate infusion that is already running and comes to the or.
I usually keep it going for the 1-3 hour case but I don’t have any data
Also I think an accrac Facebook group would be awesome.
It’d be cool for articles and questions maintaining knowledge etc
Hi Mario,
Depends on why it is running. I would have a discussion with the team from the floor or ICU to discuss why it is running and whether to keep it going. Will definitely think about the facebook idea, thanks.
Best,
Jed
Hello, Dr Jed. This podcast is fantastic. I would like to thank you for sharing such important topics with the Critical Care community.
I have the same problem here in Brazil with Bicarb administration when it comes to Cardiac postop patients. Acidosis is the terrible villain and Bicarb is the hero for our pals, cardiac surgeons. The BICAR-ICU paper and the episode 24, “The Evils of Sodium Bicarbonate” with its references are key for calling its use into question.
But even so, how hard it is to change ingrained habits in Medicine. The grip of prevailing dogma is difficult to loosen. It is more like a human psychological issue, I guess – our desperation for some sort of control over an indifferent universe – the patient.
Thanks Luciano, keep up the great work!
I would like to add that this study is done on unselected group of ICU patients. If you have a stemi patient on LV Impella support with RV failure on multiple inotropes and vasopressors and lactic acidosis, this study does not tell us if bicarb is helpful or not. Even if a patient has normal pH with low bicarb and low PaCO2, arguments can be made in favor of giving bicarb. Consider these two scenarios:
a. HCO3 = 24 mEq/L, PaCO2 = 39 Torr, arterial pH 7.4. If PaCO2 increased by 10 Torr, the resulting pH would be 7.3
b. HCO3 = 16 mEq/L, PaCO2 = 26 Torr, arterial pH 7.4. If PaCO2 increased by 10 Torr, the resulting pH would be 7.26
Scenario a has better protection against inadvertent decrease in ventilation.
Another issue is that respiratory and metabolic causes of acidosis might have different physiological effects at the cellular level. A recent animal study showed metabolic acidosis significantly blunted cardiovascular response to beta adrenergic stimulation whereas respiratory acidosis did not. A nephrology study titled “Effect of metabolic and respiratory acidosis on intracellular calcium in osteoblasts” showed different effects on Ca regulation.
Great points. What we don’t know is whether a pH of 7.3 or even 7.2 or lower is actually bad. But your point about respiratory vs metabolic is an interesting one that we need to know more about. Thanks!
In clinical scenario where lactic acid is resulting from and contributing to cardiogenic shock, the case is strong since the 2000 review by Forsythe not to give bicarbonate. However, this is frequently accompanied by AKI. When Lactic Acidosis is the primary but not isolated cause for acidosis, what are your thoughts on Bicarbonate in a patient in worsening AKI prior to the initiation of dialysis? Do you infuse 4.2% in the operating room? In the ICU? Thanks for this episode and all you do!
Hi Joe,
I think in that scenario it is totally appropriate to give bicarb, ideally 4.2%. If the kidney failure is getting worse then they’ll end up getting bicarb through dialysis so you’re just buying some time. That said, if the acidosis isn’t significant, let’s say it’s 7.25, then I don’t think there’s a rush. Different people will argue about different pH levels being “dangerous” so you have to make your own call there.