From the Guidelines
Sodium bicarbonate administration is not recommended for the treatment of lactic acidosis with a low pH, as it has not been shown to improve outcomes and may be associated with potential drawbacks. The use of sodium bicarbonate therapy to improve hemodynamics or reduce vasopressor requirements in patients with hypoperfusion-induced lactic acidemia is suggested against, especially in patients with a pH ≥ 7.15, according to the Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 1.
Key Considerations
- The evidence does not support the use of sodium bicarbonate therapy in the treatment of hypoperfusion-induced lactic acidemia associated with sepsis 1.
- Bicarbonate administration has been associated with sodium and fluid overload, an increase in lactate and Paco2, and a decrease in serum ionized calcium, but the directness of these variables to outcome is uncertain 1.
- The primary approach should focus on treating the underlying condition causing lactic acidosis, such as improving tissue perfusion, managing sepsis, or addressing other causes.
Potential Drawbacks
- Paradoxical intracellular acidosis
- Volume overload
- Hypernatremia
- Hyperosmolality
- Left shift of the oxyhemoglobin dissociation curve which can worsen tissue oxygenation
- Rapid administration of sodium bicarbonate can lead to CO2 production, potentially worsening intracellular acidosis if ventilation is inadequate.
Recommendation
In general, sodium bicarbonate should not be used as a routine treatment for lactic acidosis with low pH, and its use should be cautiously considered only in severe cases or when acidosis is compromising hemodynamic stability, while addressing the underlying cause of lactic acidosis 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 administration is indicated for severe primary lactic acidosis.
- The treatment of metabolic acidosis, including lactic acidosis with low pH, should be accompanied by measures to control the basic cause of the acidosis.
- Vigorous bicarbonate therapy is required in severe cases, such as cardiac arrest or circulatory insufficiency due to shock or severe dehydration, and in severe primary lactic acidosis 2.
From the Research
Sodium Bicarbonate Administration for Lactic Acidosis with Low pH
- The use of sodium bicarbonate for treating 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 Chest in 2000 found that the use of sodium bicarbonate to alkalinize the blood in patients with lactic acidosis has been disproved convincingly, and its use is not recommended regardless of the degree of acidemia 3.
- Another study published in Current Opinion in Critical Care in 2008 agreed with the Surviving Sepsis guidelines recommendation against the use of bicarbonate for lactic acidosis for pH at least 7.15, and further recommended a lower target pH of 7.00 or less 4.
- However, a study published in Clinical Nephrology in 1977 suggested that sodium bicarbonate may be used to treat lactic acidosis, along with restoration of adequate tissue perfusion and hemodialysis if necessary 6.
- More recent studies have suggested that other treatments, such as addressing the underlying cause of lactic acidosis, using other buffers like THAM or Carbicarb, or dialysis, may be more effective in treating lactic acidosis 4, 5.
- A case report published in Children in 2023 highlighted the importance of considering thiamine deficiency as a cause of lactic acidosis, particularly in patients with prolonged fasting and feeding difficulties 7.
Key Considerations
- The effectiveness of sodium bicarbonate in treating lactic acidosis is still a topic of debate, with some studies suggesting it may not be effective in improving outcomes 3, 4, 5.
- The use of sodium bicarbonate may have negative side effects, such as reducing serum calcium concentration and generating excess carbon dioxide with intracellular acidification 5.
- Other treatments, such as addressing the underlying cause of lactic acidosis, using other buffers, or dialysis, may be more effective in treating lactic acidosis 4, 5.