From the FDA Drug Label
Sodium Bicarbonate Injection, USP is indicated in the treatment of metabolic acidosis which may occur in severe renal disease, uncontrolled diabetes, circulatory insufficiency due to shock or severe dehydration, extracorporeal circulation of blood, cardiac arrest and severe primary lactic acidosis Vigorous bicarbonate therapy is required in any form of metabolic acidosis where a rapid increase in plasma total CO2 content is crucial - e. g., cardiac arrest, circulatory insufficiency due to shock or severe dehydration, and in severe primary lactic acidosis or severe diabetic acidosis. To treat persistent unknown lactic acidosis, sodium bicarbonate (IV) may be indicated if it is a form of metabolic acidosis or severe primary lactic acidosis.
- The treatment should be superimposed on measures designed to control the basic cause of the acidosis.
- Vigorous bicarbonate therapy is required in severe cases. 1
From the Research
Treatment of persistent unknown lactic acidosis should focus on identifying and addressing the underlying cause while providing supportive care, with the most recent and highest quality study suggesting that sodium bicarbonate administration does not improve outcomes and may even be harmful 2. The management approach should include:
- Ensuring adequate tissue perfusion by administering intravenous fluids and optimizing oxygen delivery
- Correcting any electrolyte imbalances, particularly potassium, as these can worsen acidosis
- Using vasopressors such as norepinephrine if the patient is hemodynamically unstable
- Performing comprehensive diagnostic testing to identify potential causes such as sepsis, tissue hypoperfusion, medications, malignancy, or inborn errors of metabolism
- Discontinuing any medications that could contribute to lactic acidosis
- Considering a trial of thiamine, riboflavin, or coenzyme Q10 in cases of suspected mitochondrial dysfunction
- Using continuous renal replacement therapy for severe, refractory cases, particularly if there is concurrent kidney injury, as recommended by studies such as 3 and 4. It is essential to prioritize the identification and treatment of the underlying cause, as this is the most effective way to manage lactic acidosis, rather than relying on sodium bicarbonate or other buffering agents, which have been shown to be ineffective or even harmful in some cases 5, 6.