From the Guidelines
Bicarbonate drips are not recommended for the treatment of lactic acidosis in patients with pH ≥ 7.15, as they do not improve hemodynamics or reduce vasopressor requirements 1. Instead, the focus should be on treating the underlying cause of lactic acidosis, such as improving tissue perfusion, treating infection, or addressing other primary conditions. The use of sodium bicarbonate therapy in patients with hypoperfusion-induced lactic acidemia is not supported by evidence, and it may be associated with complications such as sodium and fluid overload, an increase in lactate and Paco2, and a decrease in serum ionized calcium 1. Some key points to consider when managing lactic acidosis include:
- Treating the underlying cause of lactic acidosis
- Improving tissue perfusion
- Adequate fluid resuscitation
- Optimization of hemodynamics and oxygenation
- Avoiding the use of sodium bicarbonate therapy in patients with pH ≥ 7.15, as it is not beneficial and may be harmful 1. It is essential to note that the recommendation against the use of sodium bicarbonate therapy in patients with hypoperfusion-induced lactic acidemia with pH ≥ 7.15 is based on moderate quality of evidence and is a weak recommendation 1. However, the most recent and highest quality study available, which is the 2016 Surviving Sepsis Campaign guidelines, supports this recommendation 1. Therefore, the use of bicarbonate drips for lactic acidosis should be avoided in patients with pH ≥ 7.15, and the focus should be on treating the underlying cause and optimizing supportive care 1.
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.
Sodium bicarbonate IV is indicated for the treatment of severe primary lactic acidosis.
- The use of bicarb drip is supported in cases where rapid increase in plasma total CO2 content is crucial, such as in severe primary lactic acidosis 2.
- Bicarbonate therapy should be used to minimize risks inherent to the acidosis itself, while also addressing the underlying cause of the acidosis.
From the Research
Bicarb Drip for Lactic Acidosis
- The use of sodium bicarbonate for the treatment of lactic acidosis is a controversial topic, with some studies suggesting it may not be effective in improving outcomes 3, 4, 5.
- A study published in the journal Chest found that the use of sodium bicarbonate did not have any salutary effects and may even have negative side effects, such as reducing serum calcium concentration and generating excess carbon dioxide with intracellular acidification 3.
- Another study published in the American Journal of Kidney Diseases found that administration of sodium bicarbonate did not improve cardiovascular function or reduce mortality in patients with severe lactic acidosis 4.
- However, a study published in the journal Nephron found that massive isotonic bicarbonate infusion with simultaneous ultrafiltration was a safe and rapid method of correcting the metabolic status of patients with severe lactic acidosis who had not responded to standard therapy 6.
- The 2008 Surviving Sepsis guidelines recommend against the use of bicarbonate in patients with pH at least 7.15, while deferring judgment in more severe acidemia 5.
- Effective therapy of lactic acidosis due to shock is to reverse the cause, and other treatments such as hyperventilation, infusion of calcium, and the use of other buffers or dialysis may be considered 4, 5.