Andrew Topf

🧂Sodium Bicarbonate for Critically Ill Adults with Metabolic Acidosis and Shock: Are We Finally Closing the Debate? Sodium bicarbonate has long been one of the most controversial therapies in critical care. The newly published SODa-BIC Trial in NEJM provides the most rigorous evaluation to date. This international, double-blind, placebo-controlled RCT enrolled 500 critically ill patients with metabolic acidosis (pH <7.30) requiring vasopressor support across 55 ICUs in seven countries. Patients received either protocolized sodium bicarbonate infusion or placebo, targeting pH ≥7.30 and base excess ≥0 mmol/L. The primary endpoint was a composite of death, renal replacement therapy (RRT), or persistent renal dysfunction at 30 days. The primary outcome occurred in 40.2% of patients receiving bicarbonate versus 39.4% receiving placebo, showing no significant difference. Mortality was similar between groups (25.4% vs 24.0%), and no benefit was observed for persistent renal dysfunction or RRT dependence. Importantly, no predefined subgroup demonstrated a significant treatment effect, including patients with more severe acidemia (pH <7.25), advanced AKI, or septic shock. However, bicarbonate clearly achieved what it was designed to do physiologically. Patients receiving bicarbonate experienced faster correction of acidemia, higher bicarbonate levels, improved base excess, and significantly fewer recurrences of metabolic acidosis during the first week (32.0% vs 55.7%). Open-label bicarbonate administration was also less frequent. The key message is therefore nuanced. Bicarbonate effectively corrects laboratory abnormalities but does not improve clinically meaningful outcomes. This distinction is fundamental. Critical care history repeatedly reminds us that normalization of physiological variables does not necessarily translate into improved survival or organ recovery. The SODa-BIC trial reinforces the importance of focusing on patient-centered outcomes rather than surrogate markers alone. From a practical bedside perspective, these findings suggest: • Routine bicarbonate administration for vasopressor-dependent metabolic acidosis cannot be recommended solely to improve survival or renal outcomes. • Bicarbonate remains useful when rapid correction of severe acidemia is clinically desirable. • Decisions regarding bicarbonate therapy should remain individualized and based on the underlying cause of acidosis rather than pH correction alone. • Future studies may need to focus on highly selected phenotypes rather than treating metabolic acidosis as a homogeneous syndrome. Reference 📚 The SODa-BIC Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group. Sodium Bicarbonate for Critically Ill Adults with Metabolic Acidosis and Shock. New England Journal of Medicine. 2026. doi:10.1056/NEJMoa2600526