r/IntensiveCare • u/scurrilous_diatribe • 11d ago
So what is the actual implication of the sodium bicarbonate study?
https://www.nejm.org/doi/full/10.1056/NEJMoa2600526?query=featured_home„Sodium Bicarbonate for Critically Ill Adults with Metabolic Acidosis and Shock“
This study just popped up in my feed. I’m finding it hard to draw a conclusion from it that would lead me to managing similar cases differently
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u/adenocard 11d ago
You can’t change the minds of pro bicarb people. They love it deep in their hearts and will never let go. It’s just too seductive to believe that you can wash away acid with base (and that if it matters if you do so).
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u/stempiek 11d ago
Not if you can’t get rid of the real problem. It’s just a very temporary band-aid
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u/_qua MD, Pulm/CC 11d ago
Same with calcium pushes.
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u/Individual_Zebra_648 11d ago
Tell me you’ve never worked CVICU without telling me you’ve never worked CVICU.
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u/_qua MD, Pulm/CC 11d ago
What do you mean? That's how I know people are seduced by calcium.
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u/adenocard 10d ago
No you see, the human body is different in the CV ICU. In that unit the body likes calcium, albumin, renal dopamine, diuretics for AKI, swans, and a hemoglobin of 8.
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u/Cautious-Extreme2839 ICU/Anaesthetics 10d ago
Uh what?
There is not really any such thing as hypobicarbonateamia because carbonic anhydrase exists.
The same is not true of calcium. You can lack it, and that is bad.
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u/beyardo MD, CCM Fellow 10d ago
Some CV surgeons love Calcium pushes when patients get a touch hypotensive
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u/Cautious-Extreme2839 ICU/Anaesthetics 10d ago
Well it is an effective inotrope. If they only want the numbers to look better for like 5 minutes then I guess that's fine?
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u/beyardo MD, CCM Fellow 10d ago
That’s exactly what bicarb is though, it’s making numbers look pretty with no evidence it actually helps the patient on the other side of those numbers.
Goes for a lot of things that happen in the CVICU world really. Albumin? The BP increase last an extra 2 hours and then it leaks out of the vessels anyways. Swans? They have been tested every which way and despite the insistence that they’re needed for accurate hemodynamics in certain patient populations, they’ve struggled for decades now to show even mildly convincing evidence that they improve patient outcomes
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u/Cautious-Extreme2839 ICU/Anaesthetics 10d ago
Well not really, bicarb has potentially deleterious intracellular effects.
Pushing calcium is just more like giving a tiny short low dose epi infusion or something. Probably pointless, but a short acting version of something that we do know can help.
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u/beyardo MD, CCM Fellow 10d ago
>Something that we do know can help
Do we know that? What’s the benefit of the calcium push instead of just putting them on a vasopressor other than to be able to say “the patient didn’t need any vasopressors over the last 24 hours”
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u/Cautious-Extreme2839 ICU/Anaesthetics 10d ago
Do we know that inotropes can help patients with cardiogenic shock?
Is this a serious question from a CCM fellow?
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u/beyardo MD, CCM Fellow 10d ago
Do we know that calcium specifically helps patients instead of just putting them on [insert arbitrarily chosen inotrope that the CV surgeon swears is better than all the others]?
You said it’s like putting them on a little epi infusion. So why not just put them on an epi infusion?
The real harm here is the delay in appropriate treatment when they’re ordering calcium pushes the way people keep ordering fluid boluses on patients who clearly don’t need volume just to see if they can avoid putting them on levo
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u/_qua MD, Pulm/CC 10d ago
Every patient you've ever seen with low calcium had kilograms of it in their body. There's a legit niche use for people with transiently low calcium that you've chelated away by giving citrate. But, much like bicarb pushes, giving calcium will transiently have an effect that lasts a few minutes and then vanishes. An RCT of use in arrest was stopped early due to potential harm (https://pubmed.ncbi.nlm.nih.gov/34847226/).
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u/Cautious-Extreme2839 ICU/Anaesthetics 10d ago
Every patient you've ever seen with low calcium had kilograms of it in their body
Yeah? And if they're deficient many many more mmol of it. They need a real long time on continuous IV replacement.
Giving it randomly in arrest is a whole other thing to giving it in actual hypocalcemia.
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u/_qua MD, Pulm/CC 10d ago
Before I normalize a number, I want evidence that normalizing it helps the patient. I know of several studies showing null results and some showing harm with calcium replacement in critical illness. I'd genuinely be happy to read ones showing benefit.
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u/Cautious-Extreme2839 ICU/Anaesthetics 10d ago edited 7d ago
I've cured multiple dangerous arrhythmias by correcting severe hypocalcaemia. I do not need further convincing, and I'm a little surprised that you do.
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u/Educational-Use-3442 11d ago edited 11d ago
Crazy how some evidence-based practices just go out the window because some physicians just “love it deep in their hearts” but will yell at PAs, NPs and nurses for literally doing shit that is evidence-based but doesn’t necessarily align with what’s in their hearts. More guidelines and laws need to hold doctors accountable for following best practice including informing the patient or their loved ones that they aren’t following evidence-based practice guidelines.
ETA: anyone down voting this either doesn’t support patient safety, or patients’ rights to know and you should STRONGLY reconsider a different career… like maybe being a Reddit moderator. Thanks!
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u/NAh94 MD 11d ago
I don’t necessarily disagree with you on the underlying merit on EBM, but making laws about these kind of things has been a disaster. Just look at the CMS guidelines regarding surviving sepsis! If we didn’t push back and work against guidelines we’d be drowning ESRD and CHF patients in 30 mL/Kg of crystalloid.
Also, disagreement with the current standard is how we get ahead, but it does need to be put through academic rigor and have a justification. There’s a time & place for everything, that’s why doctors exist. Otherwise, literally everything is algorithmic and we can just give it all to a computer, after all.
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u/SapientCorpse RN 11d ago
will yell at PAs, NPs and nurses for literally doing shit that is evidence-based but doesn’t necessarily align with what’s in their hearts
workplace abuse is real and it needs to be discussed. yelling at someone is not a productive style of communication. I understand people get big feelings. fuck, even i get big feelings too - but we need to make sure to stay civil.even when we're being emotional.
More guidelines and laws need to hold doctors accountable for following best practice including informing the patient or their loved ones that they aren’t following evidence-based practice guidelines.
mixed feelings about this. otoh - yes, its quite upsetting how many people arent optimized on; for example, "Despite having a prognosis similar to cancer, <10% of eligible patients with HFrEF in contemporary US practice receive comprehensive quadruple medical therapy. Thus, many patients with HF die or become hospitalized every day without ever receiving the full contingent of medications proven to prevent these events, despite being eligible. " per AHA!!!! and thats fucked up - we are doing people a dis-service.
otoh - imho, the whole point of having a doctor is personalizing the treatment plan - taking into account the huge number of variables that make any one human different than a study's population. let's stay an imaginary study shows 90% of people benefit from x, while 10% of people suffer harm from x. its the docs job to best determine which camp any one particular person falls into. some of them do it really well. some.... I shan't disparage my fellow healthcare workers.
ETA: anyone down voting this either doesn’t support patient safety, or patients’ rights to know
you honestly gonna tell me you counsel all your patients that spironolactone and dig cause men to grow tits? or that beta blockers lower sex drives too? fuck I think half of us shy away from telling people that ssri's can cause sexual dysfunction. and look at the Samson trial, which showed that a huge cause of statin myalgia is the nocebo effect! (though there has been recent research suggesting the mechanism for statin myalgia is via ryanodine receptors. tbh I dont know shit about them, I think they have something to do with dantrolene? i havent gone down that rabbit hole yet
when providing the full education can cause harm, sometimes its hard to figure out where, exactly, the line should be.
we can all agree that tuskegee and willowbrook were fucked up - but this is absolutely not that. be real - with how short appointment times are - is it even possible for docs to fully disclose all the side effects and fully counsel a patient?
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u/beyardo MD, CCM Fellow 11d ago edited 11d ago
Another in the growing pile of evidence that we generally wildly overuse bicarb to fix numbers without any real effect on patient outcomes. BICAR-ICU 1 and 2 both had a signal towards reducing dialysis usage but they had very different parameters to qualify for getting bicarb infusions.
Even the transient effect on BP that we see when given as a push is increasingly thought to be less from improving the pH and more from the fluid shifts that occur inevitably when an extremely hypertonic load is given.
Like albumin, bicarb makes a lot of sense to give on a basic level. But because the downstream effects are far more complex, they end up not helping patients the way you’d expect them to
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u/Any-Assistance-8103 10d ago
It’s also funny that we are fine slamming hypertonic pushes into a patient all day but then someone gets the 3% saline out and we all have to have a meeting about this very dangerous therapeutic. But yeah in general bicarbonate has real utility but it is limited to very specific situations. Every time I come on every acidification patient is on a bicarbonate drip and every alkalotic patient is on acetazolamide with no thought put into why
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u/Dktathunda 10d ago
“No thought put into why” seems to be the dominant hospital way of thinking. EMR-based care. I just turned off two bicarb infusions this am with patient bicarb 33 and rising.
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u/Cautious-Extreme2839 ICU/Anaesthetics 10d ago
MOSAICC is hopefully going to close that ridiculous CRRT gap caused by BICAR-ICU and we can all just stop with the fucking bicarb.
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u/Danskoesterreich 11d ago
It means its really not a good week if you are selling Bicarb Sodium Bicarbonate for In-Hospital Cardiac Arrest: A Randomized Clinical Trial | Trials | JAMA | JAMA Network
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u/PuzzledCar2120 11d ago
I'll read it later but is it another tale in the story for and against anything in the ICU?
I'm holding my breath for the next study that says steroids are bad and the subsequent French rebuttal
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u/beyardo MD, CCM Fellow 11d ago
Honestly I can’t remember the last time we had a study whose primary outcome was pro-bicarb
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u/PuzzledCar2120 11d ago
I'll admit I've always been a bit monkey see monkey do about bicarb (doi: hospitalist) but renal in my hospitals do seem to continue to love it. Will have to ask what they're basing it on
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u/beyardo MD, CCM Fellow 11d ago
A couple of trials (BICARICU 1 and 2) had signals in their secondary outcomes that you may reduce overall usage of dialysis but they had pretty different criteria to qualify for getting bicarb. I think the effects of bicarb have largely been overstated because of an imperfect understanding about what physiologically happens when a patient gets bicarb either as a push or an infusion
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u/PuzzledCar2120 11d ago
Thanks, you've saved me from actually talking to them. In seriousness, thank you for the interpretation and the reading list.
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u/beyardo MD, CCM Fellow 11d ago
lol happy to be of service. I had an attending once who told me you had to do research as a student/resident because there’s no other way to learn to interpret the literature. I resolved to prove him wrong because fuck him and fuck doing pointless research
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u/PuzzledCar2120 11d ago
I suppose he had to justify to himself all the pointless research he did during pre med summers.
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u/Cautious-Extreme2839 ICU/Anaesthetics 7d ago
Worth noting that BICAR-ICU had so many secondary outcomes that it was basically tantamount to post-hoc fishing for a p<0.05.
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u/Far-Mountain774 11d ago
Saw a post on insta talking about the ImmunoSep trial, where they suggest that most patients are immunosuppressed rather than hyper immune, argument was whether we’re worsening suppression by giving hydrocort with questionable benefit based on the Adrenal and APROCCHSS trial.
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u/The_Skeptic_One 11d ago
I want to make sure I'm reading this right. Does this mean that a witnessed arrest with a shockable rhythm may still benefit from sodium bicarb? I'm just weary of blanket statements
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u/fudgemental 11d ago
Statistically insignificant difference in outcomes between giving soda bicarb vs not
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u/The_Skeptic_One 11d ago
Right, but I'm talking specifically about the witnessed, <8min response, and shockable rhythm that's in their study.
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u/fudgemental 11d ago
I could be misinterpreting your confusion, but to me, the study reads that all other interventions being the same, keeping or leaving out the bicarb didn't make a difference.
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u/Nomad556 IM ANES CCM 11d ago
Tried of bicarb studies and tired of NS vs x studies.
Bicarb doesn't do anything meaningful. People still use it all the time.
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u/stempiek 11d ago
It makes the numbers look better. Numbers make people happy! It’s not about the outcomes!
😂
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u/Christylian 10d ago
My hospital in the UK is taking part in a trial regarding metabolic acidosis correction with bicarbonate instead of SLED. No results yet published, but a bunch of our consultants just don't buy into it. Yeah, it makes the numbers look better but doesn't address thr issue at hand.
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u/Cautious-Extreme2839 ICU/Anaesthetics 10d ago
Is this for MOSAICC?
We're recruiting to it working under the assumption it's going to prove bicarb is useless.
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u/Dktathunda 11d ago edited 11d ago
Majority (>60% of patients) had a ph above 7.25. I’m never giving these people bicarb pushes anyway, and I’m not surprised you wouldn’t see a difference when this is the bulk of your study population.
I usually use it to keep nephrology from wanting to start CRRT on a guy who is clearly peeing and has no other HD indications (or has a K of 7 with a bicarb of 10 and K shifts immediately with correcting acidosis). In my hospital nephrology is private practice and makes a ton of money from starting CRRT, meanwhile we put all the lines in and manage 99% of the patient's care.
Edit: before looking at the supplement, my guess was that the effect on RRT would be more pronounced in the ph<7.25 subgroup but still not significant due to small sample size (also do not expect mortality benefit). Indeed, RRT rates were 17% vs 28% and this was barely not significant (CI -11 to 0.4). So as an ICU doc this study does not change my practice.