🟢 Strong Evidence
Sodium bicarbonate therapy does not reduce mortality in critically ill adults with metabolic acidosis and shock, according to the largest randomized controlled trial to date. The BICAR-ICU trial, published in The New England Journal of Medicine, found no significant difference in 28-day mortality between patients receiving sodium bicarbonate and those receiving standard care.
Key takeaways
- Sodium bicarbonate did not reduce 28-day mortality compared to standard care in critically ill patients with shock
- The trial included 3,396 adults across multiple intensive care units, making it the definitive study on this intervention
- Results challenge decades of clinical practice where bicarbonate has been routinely used to correct severe acidosis
Study at a Glance
| Source | New England Journal of Medicine |
| Study type | Randomized controlled trial |
| Sample size | N = 3,396 |
| Population | Critically ill adults with metabolic acidosis and shock |
| Country | France (multicenter) |
28-Day Mortality Outcomes by Treatment Group
No significant difference between sodium bicarbonate and standard care
Source: BICAR-ICU Trial, NEJM 2024 | Georgian Medical Journal News
Large International Trial Challenges Standard Practice
The BICAR-ICU trial represents a significant shift in understanding of bicarbonate therapy for critically ill patients. Researchers from the Assistance Publique-Hôpitaux de Paris led the multicenter study across French intensive care units, recruiting patients with severe metabolic acidosis and circulatory shock.
Participants were randomized to receive either intravenous sodium bicarbonate or standard care without bicarbonate supplementation. The primary endpoint was mortality at 28 days, with secondary endpoints including organ failure scores and length of intensive care stay. For more evidence-based critical care research, see our clinical updates section.
No Mortality Benefit Despite Theoretical Rationale
The trial found 28-day mortality rates of 32.7% in the bicarbonate group compared to 31.5% in the control group, a difference that was not statistically significant. Secondary outcomes also showed no meaningful differences between groups, including rates of organ failure and time to recovery.
These findings contradict the theoretical benefits of bicarbonate therapy, which include correcting acidosis and potentially improving cardiovascular function. Previous smaller studies had suggested possible benefits, but this large-scale trial provides definitive evidence against routine bicarbonate use. The European Society of Intensive Care Medicine has previously issued guidelines on acidosis management that may now require revision.
Implications for Critical Care Practice Worldwide
The results challenge current clinical practice in many intensive care units where sodium bicarbonate is routinely administered to patients with severe acidosis. Dr. Djillali Annane, the study’s principal investigator from Raymond Poincaré Hospital, noted that the findings should prompt reconsideration of bicarbonate therapy protocols.
The study’s robust methodology, including adequate randomization and blinding procedures, strengthens confidence in the results. With over 3,000 participants, the trial had sufficient statistical power to detect clinically meaningful differences in mortality if they existed. For related intensive care research from Georgian institutions, visit our Georgian research section.
Future Research Directions and Clinical Guidelines
While this trial provides strong evidence against routine bicarbonate use, questions remain about specific subgroups who might benefit from the intervention. Future research may focus on patients with extreme acidosis or specific underlying conditions where bicarbonate therapy could still play a role.
Clinical guidelines from major critical care societies will likely need updating based on these findings. The Society of Critical Care Medicine and other professional organizations typically review such landmark studies when revising treatment recommendations.
28-day mortality showed no significant difference between bicarbonate therapy (32.7%) and standard care (31.5%) in 3,396 critically ill adults with metabolic acidosis and shock
— BICAR-ICU Investigators, Multiple French ICUs (New England Journal of Medicine, 2024)
What this means
Frequently asked questions
Does this mean bicarbonate therapy should never be used in ICU patients?
The study shows no benefit for routine use in metabolic acidosis with shock. However, bicarbonate may still have specific indications like severe hyperkalemia or certain poisonings that weren’t studied in this trial.
Why was bicarbonate therapy used if it doesn’t work?
Previous smaller studies and theoretical benefits led to widespread adoption. This large trial provides the first definitive evidence that routine use doesn’t improve survival in critically ill patients.
Will this change ICU treatment protocols immediately?
Major medical societies typically review landmark studies before updating guidelines. Individual hospitals may begin revising protocols based on this strong evidence, but widespread changes will likely take months to years.
The BICAR-ICU trial represents a paradigm shift in critical care medicine, demonstrating how large-scale randomized trials can definitively answer long-standing clinical questions. As intensive care units worldwide review their protocols, this study will likely influence treatment decisions for thousands of critically ill patients annually. The findings underscore the importance of evidence-based medicine in challenging established practices, even when they appear physiologically reasonable.
Source: Sodium Bicarbonate for Critically Ill Adults with Metabolic Acidosis and Shock
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Medically reviewed by Prof. Giorgi Pkhakadze, MD, MPH, PhD. Spotted an error? Contact the editorial team.
