Intensive Care Medicine
Published: 10 June 2025, Volume 51, pages
1–9, (2025)
Purpose
Sodium bicarbonate is commonly administered to treat
metabolic acidosis in intensive care units (ICUs). There is limited evidence
from randomized trials to support this practice, and observational studies show
conflicting results. Our aim was to perform a target trial emulation evaluating
the effect of bicarbonate therapy on mortality.
Methods
Retrospective cohort study using data from 12 Australian
ICUs. Inclusion criteria were adults with pH < 7.3 and PCO2 ≤ 45 mmHg within the first
three days. We excluded repeat admissions, toxicology, diabetic ketoacidosis,
and pre-existing end-stage renal failure. The treatment intervention was
sodium-bicarbonate administration, and the primary outcome was 30-day ICU
mortality with ICU discharge as a competing event. We evaluated multiple
subgroups, including patients with acute kidney injury, requirement for
vasoactive therapy, and pH < 7.2. The primary model utilized
a parametric g-computation and rolling entry matching was performed as a
sensitivity analysis.
Results
We identified 6157 eligible admissions, of which 1764 (29%)
received sodium bicarbonate. Bicarbonate therapy was associated with a 1.9%
absolute mortality reduction for the primary analysis [risk ratio 0.86, 95%
confidence interval (CI) 0.80 to 0.91], and significant benefits were seen
across all subgroups evaluated. A similar point estimate of 2.1% was observed
in the sensitivity analysis, with a sustained mortality reduction seen at
30 days.
Conclusion
In this target trial emulation, bicarbonate administration
was associated with a small but statistically significant reduction in
mortality for patients with metabolic acidosis. Large sample sizes would be
required to demonstrate this effect in a randomized trial.
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