Saturday, January 25, 2020

Bicarbonate in Lactic Acidosis?

I would like to make this perfectly clear, this article has many nuisances to it. Many limitations and different components that need to be dissected carefully. Too carefully for what I can do on IG. Please attempt to obtain it and read it for yourself as it does not provide a black and white response to the question: can we treat lactic acidosis with bicarb?
The slides presented here are preliminary slides from my lectures that I am actively working on. I plan on explaining things in far more detail to my audience than what is on the slides. Is that enough of a disclaimer? Well then let's let it rip!
There exists a pendulum in many things medicine and providing bicarb in lactic acidosis patients is one of them. There's always been the question of whether it's beneficial, ineffective or harmful. If you look at the data pre-2000, it is almost entirely supportive of not providing bicarb for these patients. The data after 2001 is more lenient to where it is discussed in one paper that "bicarbonate might prolong survival sufficiently to allow treatment of the underlying cause of lactic acidosis". This is why I use the term "bicarb band-aid" whenever I put someone on a bicarb drip to buy some time to figure things out. 
Like everything in medicine, bicarb drips have their drawbacks. I know people LOVE to give amps of bicarb during ALCS but there's no data to do so. Much more to that than what I'm going to discuss here. Very broad topic. 
Getting back to the article. They took almost 400pts in France who were very sick, with a lactic acidosis, and randomized them to get either nothing or 4.2% bicarb gtt. They had some very strange outcomes which are a conversation for another day but ultimately, patients who had acute kidney injury did better, and this is even considering that 24% of the control group got bicarb. Nonetheless, the numbers are explained in the slides. 
Again, is this black and white? Nope. But it's the first large RCT in this patient population looking at this intervention and major hat tips to the authors. 

-EJ

PS: Can I take credit for the term "bicarb band-aid"? I'd like to but I feel that I'm not original enough to have come up with it. 





Link to Article

Jaber S, Paugam C, Futier E, et al. Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomised controlled, phase 3 trial. Lancet 2018; 392:31.

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