Design: Pragmatic, adaptive, double-blind, placebo-controlled RCT
Population: 500 ICU adults with metabolic acidosis on vasopressors in 7 countries
Primary outcome: Major adverse kidney events within 30 days
Effect: 40.2% vs 39.4%; adjusted difference 1.2 points (95% CI −7.1 to 9.4)

SODa-BIC, a pragmatic adaptive double-blind trial in 55 ICUs across seven countries, randomised 500 adults with metabolic acidosis (pH below 7.30, base excess −4 or lower, and no respiratory acidosis) who were on vasopressors to sodium bicarbonate or placebo (5% dextrose), infused for up to five hours towards a pH of 7.30 or above. It was published in June.

Major adverse kidney events at 30 days — death, renal replacement therapy or persistent renal dysfunction — occurred in 40.2% with bicarbonate and 39.4% with placebo (adjusted difference 1.2 points, 95% CI −7.1 to 9.4). Renal replacement therapy (16.8% vs 20.9%) and 30-day mortality (25.4% vs 24.0%) did not differ significantly. Four patients had an adverse effect with bicarbonate, none with placebo.

An earlier trial had suggested benefit in the subgroup with acute kidney injury, which kept bicarbonate in use. This larger, blinded trial did not find it. Routine bicarbonate to correct the pH in shock is not supported.

Do not give sodium bicarbonate routinely to correct metabolic acidosis in patients on vasopressors.
Focus on restoring perfusion and treating the cause: fluids, vasopressors, source control.
Continue bicarbonate for specific indications — sodium-channel blocker toxicity, severe hyperkalaemia, bicarbonate loss.
Watch for sodium and fluid load, hypokalaemia and ionised hypocalcaemia if bicarbonate is given.
Consider early renal replacement therapy for refractory acidosis with kidney failure rather than repeated bicarbonate.

Why it matters

It removes the main trial-based reason for bicarbonate in septic and other shock with acidosis.

The statistics, in plain English

The adjusted difference of 1.2 percentage points has a confidence interval from −7.1 to 9.4, which crosses zero — no detectable effect. The trial could not exclude a modest benefit or harm, and the dialysis difference (−3.9 points, −10.6 to 2.7) is not significant.