Incidence and management of metabolic acidosis with sodium bicarbonate in the ICU: An international observational study

Abstract

Background Metabolic acidosis is a major complication of critical illness. However, its current epidemiology and its treatment with sodium bicarbonate given to correct metabolic acidosis in the ICU are poorly understood. Method This was an international retrospective observational study in 18 ICUs in Australia, Japan, and Taiwan. Adult patients were consecutively screened, and those with early metabolic acidosis (pH < 7.3 and a Base Excess < –4 mEq/L, within 24-h of ICU admission) were included. Screening continued until 10 patients who received and 10 patients who did not receive sodium bicarbonate in the first 24 h (early bicarbonate therapy) were included at each site. The primary outcome was ICU mortality, and the association between sodium bicarbonate and the clinical outcomes were assessed using regression analysis with generalized linear mixed model. Results We screened 9437 patients. Of these, 1292 had early metabolic acidosis (14.0%). Early sodium bicarbonate was given to 18.0% (233/1292) of these patients. Dosing, physiological, and clinical outcome data were assessed in 360 patients. The median dose of sodium bicarbonate in the first 24 h was 110 mmol, which was not correlated with bodyweight or the severity of metabolic acidosis. Patients who received early sodium bicarbonate had higher APACHE III scores, lower pH, lower base excess, lower PaCO2, and a higher lactate and received higher doses of vasopressors. After adjusting for confounders, the early administration of sodium bicarbonate was associated with an adjusted odds ratio (aOR) of 0.85 (95% CI, 0.44 to 1.62) for ICU mortality. In patients with vasopressor dependency, early sodium bicarbonate was associated with higher mean arterial pressure at 6 h and an aOR of 0.52 (95% CI, 0.22 to 1.19) for ICU mortality. Conclusions Early metabolic acidosis is common in critically ill patients. Early sodium bicarbonate is administered by clinicians to more severely ill patients but without correction for weight or acidosis severity. Bicarbonate therapy in acidotic vasopressor-dependent patients may be beneficial and warrants further investigation.

Effectiveness of sodium bicarbonate infusion on mortality for elderly septic patients with acute metabolic acidosis

“…The above findings in this study can be summarized as follows: ( Vincent and Abraham, 2006 ): There was no association between SB infusion treatment and reduced ICU or hospital mortality overall in elderly septic patients with acute MA or in the subgroup of acute SMA; ( Yahav et al, 2016 ); SB infusion was associated with reduced both ICU and hospital mortality for elderly septic patients in the subgroup of acute MMA. The current studies demonstrated that acute MA was frequently observed in the older critical patients with sepsis, and SB was commonly used in such patients but there was lack of evidence about its effect on mortality ( Englert and Ross, 2015 ; Ganesh et al, 2016 ; Martin-Loeches et al, 2019 ; Fujii et al, 2021 ). Therefore, this is the first clinical investigation providing the evidence that SB infusion could improve both ICU and hospital survival for elderly septic patients with acute MMA.…”

A rare case report of combined metformin-associated lactic acidosis and diabetic ketoacidosis

“…Treatment with sodium bicarbonate should be reserved for patients in ICU with high anion-gap metabolic acidosis, particularly severe lactic acidosis. It is independently associated with increased mean arterial pressure and reduced ICU mortality in this group of patients [17,18]. But sodium bicarbonate alone may not be sufficient to correct the severe acidosis seen in these patients.…”

Management of acute metabolic acidosis in the ICU: sodium bicarbonate and renal replacement therapy

“…A recently published international observational study conducted in 18 ICUs in Australia, Japan, and Taiwan reported that 14% (1292/9437) of critically ill patients had moderate or severe metabolic acidosis [9]. The median incidence of metabolic acidosis at a study ICU was 172.5 patients/year, suggesting that the management of metabolic acidosis is a relevant issue in patient care in the ICU.…”

“…A recent international observational study revealed that 18% of patients with moderate or severe metabolic acidosis receive sodium bicarbonate in current clinical practice [9]. However, the total amount of sodium bicarbonate given during the first 24 h of metabolic acidosis was 110 mmol, which was not adjusted for body weight or base excess.…”