Bicarbonate therapy in the treatment of septic shock: a second look

Abstract

The use of supplemental sodium bicarbonate for the treatment of patients with septic shock and elevated blood lactate levels remains a controversial therapy. We conducted a retrospective study between March 2004 and February 2009 of 36 consecutive patients diagnosed with septic shock who received continuous infusion of bicarbonate therapy. A control group was matched 1:1 for age, site of infection, and predicted mortality by APACHE II. All patients were managed according to standard protocols. The median time until reversal of shock did not achieve statistical significance between the bicarbonate group (44.5 h [95% confidence interval [CI] 34-54] and the control group (55.0 h [95% CI 39-60] (p = 0.09). The median time to liberation of mechanical ventilation was significantly reduced in the bicarbonate group (10 days [95% CI 5.0-13.0] compared to the control group (14 days [95% CI 9.0-19.0], p = 0.02). The length of intensive care unit (ICU) stay was also shorter in the surviving patients who received bicarbonate compared to controls (median 11.5 days (95% CI 6.0-16.0) vs. 16.0 days (95% CI 13.5-19.0), respectively; p = 0.01). However, there was no difference in 28-day mortality between the two study groups (28%; 95% CI 14-45% vs. 33%; 95% CI 19-51%, respectively; p = 0.79). Infusion of sodium bicarbonate in septic patients with arterial hyperlactatemia may facilitate weaning from mechanical ventilation and reduce length of ICU stay.

Sodium Bicarbonate Therapy in Patients with Metabolic Acidosis

“…In patients diagnosed with septic shock, sodium bicarbonate therapy has not been associated with improvement of hemodynamic variables or mortality rate in retrospective [38] and prospective [39] studies. Accordingly, the 2008 update of the Surviving Sepsis Campaign guidelines recommends against the use of sodium bicarbonate in patients with hypoperfusion-induced lactic acidosis and pH ≥ 7.15 [40].…”

“…A reduction in the serum potassium level has been observed following sodium bicarbonate administration in patients with septic shock [38] and stage 5 CKD [94]. During DKA management, an increase in the amount of potassium required to maintain a normal plasma value has been detected in patients treated with sodium bicarbonate by some [30, 95] but not all [24] studies.…”

“…Sodium bicarbonate infusion reduces plasma ionized calcium concentration in critically ill patients with metabolic acidosis [21, 38]. In vitro, bicarbonate concentration has a major effect reducing ionized calcium level in serum [96].…”

Place des solutions de bicarbonate de sodium en réanimation

“…Cooper et al ont rapporté des résultats comparables chez 14 patients de réanimation présentant une acidémie lactique sévère (> 5 mmol/L) [19]. Des études observationnelles cas-témoins plus récentes rapportent des effets bénéfiques de l'alcalinisation par bicarbonate de sodium des patients critiques avec une diminution de la durée de l'acidémie, la durée de ventilation mécanique et la durée de séjour en réanimation [20] mais certaines rapportent à l'inverse un effet délétère sur la survie [21]. En 2014, Fang et al ont conduit une étude randomisée contrôlée multicentrique et retrouvent des effets bénéfiques de la perfusion de bicarbonate de sodium à 5 % comme soluté de remplissage comparé à du soluté salé isotonique ou hypertonique sur la pression artérielle moyenne et le débit cardiaque chez des patients en choc septique [22].…”

Sodium Bicarbonate—The Swings and Roundabouts Will Not Stop Without Randomized Evidence*

“…Although early discouraging publications followed, widespread use continued (2). American and European critical care societies now discourage its use (3)(4)(5); however, controversy on its potential benefits continues, for all age groups: from treatment of newborns (6,7) through to pediatrics (8) and adult ICU medicine (9). This is fueled by confiicting results from retrospective cohorts.…”