Journal Article Ahead of print 3 citations
PubMed: 42472834 DOI: 10.1186/s13054-026-06206-3
Sodium bicarbonate therapy in severe metabolic acidemia: an individual patient data meta-analysis of the BICAR-ICU and BICAR-ICU2 trials.
Crit Care
Authors: Maxime Fosset, Joris Pensier, Matthieu Jabaudon, Laurent Bitker, Audrey De Jong, Gerald Chanques, Helena Huguet, Nicolas Molinari, Samir Jaber, Boris Jung
Affiliations
- Medical Intensive Care Unit, CHU Montpellier, 191, Avenue du Doyen Gaston Giraud, Montpellier, Cedex 5, 34295, France. IDESP, Univ Montpellier, INSERM, PreMEdical, INRIA, CHU Montpellier, Montpellier, France, University of Montpellier, Montpellier, 34295, France.
- Department of Anesthesia and Intensive Care unit, St-Eloi Hospital, Regional University Hospital of Montpellier, University of Montpellier, CEDEX 5, Montpellier, France.
- University of Montpellier, INSERM U1046, CNRS UMR, Montpellier, 9214, France.
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France.
- CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France.
- Medical Intensive Care Unit, La Croix Rousse Hospital, Lyon, France.
- Lyon University Hospital, Lyon, France.
- Epidemiology and Clinical Research Department, Montpellier University Hospital, Université de Montpellier, Montpellier, France.
- IDESP, Univ Montpellier, INSERM, PreMEdical, INRIA, CHU Montpellier, Montpellier, France, University of Montpellier, Montpellier, 34295, France.
- Medical Intensive Care Unit, CHU Montpellier, 191, Avenue du Doyen Gaston Giraud, Montpellier, Cedex 5, 34295, France.
- University of Montpellier, INSERM U1046, CNRS UMR, Montpellier, 9214, France.
Abstract
BACKGROUND
Two randomized trials (BICAR-ICU and BICAR-ICU2) evaluated intravenous sodium bicarbonate therapy in patients with severe metabolic acidemia but yielded inconclusive results. We performed an individual patient data meta-analysis to assess its effects on 90-day mortality and renal replacement therapy (RRT) use, and search for heterogeneity of treatment effects across prespecified subgroups.
METHODS
We performed an individual patient data meta-analysis of the BICAR-ICU and BICAR-ICU2 trials, including adults with severe metabolic acidemia (pH ≤ 7.20). Patients were randomized to receive intravenous sodium bicarbonate titrated to a pH ≥ 7.30 or no sodium bicarbonate. The primary outcome was 90-day mortality. Secondary outcomes included RRT initiation and dialysis-free days. Prespecified subgroup analyses explored treatment-effect heterogeneity by acidemia depth (pH ≤ 7.10 vs. > 7.10), severe acute kidney injury (AKI) status, and serum lactate (< 2mmol/L vs. ≥2mmol/L).
RESULTS
A total of 1,016 patients was included (509 sodium bicarbonate, 507 control). Sodium bicarbonate therapy did not significantly reduce 90-day mortality compared to control (58.3% vs. 60.6%; risk ratio [RR], 0.96; 95%CI, 0.86-1.07; p = 0.51). However, it significantly reduced RRT initiation (34.8% vs. 50.7%; RR, 0.69; 95%CI, 0.60-0.79; p < 0.001, number needed to treat: 6.3) and increased dialysis-free days (incidence rate ratio, 1.10; 95%CI, 1.06-1.14; p < 0.001). A significant interaction was observed with acidemia depth (p-for-interaction = 0.006): in patients with pH ≤ 7.10, sodium bicarbonate reduced 90-day mortality (RR, 0.80; 95%CI, 0.68-0.93; p = 0.004); no benefit was seen with pH > 7.10 (RR, 1.05; 95%CI, 0.92-1.21; p = 0.47). No significant interactions were observed for severe AKI status (p-for-interaction = 0.11) nor serum lactate (p-for-interaction = 0.22).
CONCLUSIONS
Sodium bicarbonate therapy did not reduce overall 90-day mortality but decreased RRT use and suggested a mortality benefit in patients with the most profound acidemia (pH ≤ 7.10). These findings invite a reconsideration of current paradigms, suggesting timely correction of severe metabolic acidemia to avoid RRT in some patients.
MeSH
Mortality, Serum, Incidence, Therapeutics