Bicarbonate Therapy for Critically Ill Patients with Metabolic Acidosis: A Systematic Review

Abstract

The management of acid-base disorders always calls for precise diagnosis and treatment of the underlying disease. Sometimes additional means are necessary to combat systemic acidity itself. In this systematic review, we discuss the concept and some specific aspects of bicarbonate therapy for critically ill patients with metabolic acidosis (i.e., patients with blood pH < 7.35). We conducted a systematic literature review of three online databases (PubMed, Google Scholar, and Cochrane) in November 2018 to validate usage of bicarbonate therapy for critically ill patients with metabolic acidosis. Twelve trials and case series were included in the final analysis, from which we assessed population, intervention, comparison, and outcome data. The current literature suggests limited benefit from bicarbonate therapy for patients with severe metabolic acidosis (pH < 7.1 and bicarbonate < 6 mEq/L). However, bicarbonate therapy does yield improvement in survival for patients with accompanying acute kidney injury.

Severe metabolic acidosis due to acetazolamide intoxication in a dog

“…Previously, self‐resolution of the acid–base abnormalities was recorded in a cat with topical dorzolamide administration 3 . However, due to the extremely high dose ingestion (21× that of previously reported in the literature) and the severe clinical and metabolic changes, sodium bicarbonate therapy was deemed necessary 21 . Furthermore, even with supplementation, it took 5 days for the resolution of acidaemia.…”

“…Furthermore, even with supplementation, it took 5 days for the resolution of acidaemia. In contrast to cases that are presented with metabolic acidosis with an increased anion gap, sodium bicarbonate therapy is deemed safe 21 . Potential complications of sodium bicarbonate therapy include increased lactate production (further contributing to the metabolic acidosis), hypernatraemia and hyperosmolality.…”

“…Potential complications of sodium bicarbonate therapy include increased lactate production (further contributing to the metabolic acidosis), hypernatraemia and hyperosmolality. If administered in any case, a compatible solution, such as 5% dextrose in water, should be selected for dilution 21 …”

“…In human patients with CAI overdose, despite the high intraerythrocytic distribution and plasma‐binding properties, 22 dialysis to assist in more rapid removal of the drug is a possible treatment option 14 . This is particularly useful in human patients with renal failure due to the high renal excretion rate of the drug and the danger that exists with the administration of sodium bicarbonate in these patients 21 . In humans, death has been associated with the use of acetazolamide in chronic renal failure patients 23…”

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“…Metabolic acidosis is a condition when blood pH < 7.35 due to reduced bicarbonate (HCO 3-) levels in the blood those further worsen with the decrease in arterial partial pressure of carbon dioxide (PaCO2). For every 1 mmol/L fall in serum HCO 3there will be ~ 1 mmHg decrease in PaCO2 that will fall the blood pH < 7.20 [28]. According to Henderson-Hasselbalch method, metabolic acidosis is a state when concentration of (HCO3 -) is below 20 mmol/L in blood plasma [29].…”