- Design
- Systematic review and Bayesian random-effects meta-analysis of 4 RCTs
- Population
- 1544 critically ill adults with metabolic acidosis
- Primary outcome
- Short-term all-cause mortality
- Effect
- Mortality RR 0.94 (CrI 0.73 to 1.22); RRT initiation RR 0.74 (0.59 to 0.98)
This Bayesian meta-analysis pooled four randomised trials of intravenous sodium bicarbonate against placebo or usual care in 1544 critically ill adults with metabolic acidosis, searching to April 2026.
Short-term mortality was not clearly lower (relative risk 0.94, 95% credible interval 0.73 to 1.22), with a 72% probability of any benefit. Initiation of renal replacement therapy was lower (0.74, 0.59 to 0.98), with a 97.2% probability of benefit. Other outcomes were small or imprecise, and no consistent safety signal appeared.
For emergency physicians and intensivists, this supports considering bicarbonate in severe metabolic acidosis, particularly with acute kidney injury, as a way to avoid or delay dialysis — important where dialysis capacity is limited, as in many Indian hospitals. It does not support bicarbonate to improve survival, and the patients most likely to benefit still need defining. Watch sodium, fluid load and ionised calcium.
- Consider intravenous bicarbonate in severe metabolic acidosis with acute kidney injury in the ICU.
- Do not expect a survival benefit from bicarbonate on current evidence.
- Monitor sodium, volume status and ionised calcium during infusion.
- Treat the cause of the acidosis; bicarbonate is supportive.
Why it matters
Avoiding dialysis is a real benefit where machines and staff are scarce.
Don't overread it
No clear survival benefit; the renal finding rests on four trials.
The statistics, in plain English
A credible interval is the Bayesian version of a confidence interval. For dialysis, 0.59 to 0.98 sits wholly below 1, and the 97.2% figure is the probability that bicarbonate reduces dialysis at all. For mortality, the interval spans benefit and harm. Four trials is a small base.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for emergency & critical care, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free