The edition · Emergency & Critical Care
Bicarbonate in metabolic acidosis: no clear survival gain, but probably less dialysis
A Bayesian meta-analysis of four ICU trials puts a 97% probability on fewer renal replacement starts with sodium bicarbonate. Also: cardiac arrest during paediatric intubation, who gains from high-flow oxygen when immunocompromised, and capillary refill-guided resuscitation.
The edition in brief
Today's emergency and critical care edition closes on a Bayesian meta-analysis of four randomised trials (1544 patients) of intravenous sodium bicarbonate for metabolic acidosis in ICU adults. Mortality was not clearly lower (relative risk 0.94, 95% credible interval 0.73 to 1.22), but initiation of renal replacement therapy probably was (relative risk 0.74, 0.59 to 0.98; 97.2% probability of benefit), with no consistent safety signal. A registry of 27,773 intubations in paediatric ICUs found cardiac arrest in 1.2%, with higher odds in shock and with each extra attempt, and lower odds with video laryngoscopy, ketamine, propofol and neuromuscular blockade. A machine-learning reanalysis of the HIGH trial suggested high-flow nasal oxygen may prevent intubation in a subgroup of immunocompromised patients despite no average benefit. A meta-analysis of seven trials in septic shock found capillary refill-guided resuscitation gave a mortality risk ratio of 0.87 (95% CI 0.76 to 1.01). The pearl covers how to measure capillary refill time properly.
Intubating critically ill children: each extra attempt raised the odds of cardiac arrest by 70%
Resuscitate before intubating a critically ill child and aim for first-pass success, since each extra attempt was linked to markedly higher arrest odds.
High-flow oxygen in immunocompromised respiratory failure: no average benefit, but perhaps a responsive subgroup
High-flow oxygen may help some immunocompromised patients with respiratory failure more than others; keep a low threshold to intubate those failing on it.
Capillary refill-guided resuscitation in septic shock: mortality estimate lower, not yet proven
Capillary refill time is a reasonable, low-cost guide to resuscitation in septic shock, though a mortality benefit is not yet confirmed.
Measure capillary refill time the same way every time
Standardise capillary refill: fingertip pad, firm pressure for ten seconds, hand at heart level, timed with a watch.
Sodium bicarbonate for ICU metabolic acidosis: high probability of less dialysis
In severe metabolic acidosis in the ICU, especially with acute kidney injury, consider sodium bicarbonate to reduce the need for dialysis, not to improve survival.
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