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Is there a role for sodium bicarbonate in treating lactic acidosis from shock?

Boyd, John H; Walley, Keith R

Current Opinion in Critical Care: August 2008 - Volume 14 - Issue 4 - p 379–383
doi: 10.1097/MCC.0b013e3283069d5c
Pharmacology, metabolism and nutrition: Edited by Stanley A. Nasraway

Purpose of review Bicarbonate therapy for severe lactic acidosis remains a controversial therapy.

Recent findings The most recent 2008 Surviving Sepsis guidelines strongly recommend against the use of bicarbonate in patients with pH at least 7.15, while deferring judgment in more severe acidemia. We review the mechanisms causing lactic acidosis in the critically ill and the scientific rationale behind treatment with bicarbonate.

Summary There is little rationale or evidence for the use of bicarbonate therapy for lactic acidosis due to shock. We agree with the Surviving Sepsis guidelines recommendation against the use of bicarbonate for lactic acidosis for pH at least 7.15 and we further recommend a lower target pH of 7.00 or less. If bicarbonate is used, consideration must be given to slow infusion and a plan for clearing the CO2 that is produced and measuring and correcting ionized calcium as the resultant 10% drop may decrease cardiac and vascular contractility and responsiveness to catecholamines. When continuous renal replacement therapy is used during severe acidosis, we recommend bicarbonate-based replacement fluid over citrate as citrate may increase the strong ion gap. Effective therapy of lactic acidosis due to shock is to reverse the cause.

University of British Columbia, Critical Care Research Laboratories, Vancouver, British Columbia, Canada

Correspondence to Keith R. Walley, MD, Critical Care Research Laboratories, 1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6 Tel: +1 604 806 8136; e-mail:

© 2008 Lippincott Williams & Wilkins, Inc.