Risk Potential for Organ Dysfunction Associated With Sodium Bicarbonate Therapy in Critically Ill Patients With Hemodynamic Worsening

Background: The role of sodium bicarbonate therapy (SBT) remains controversial. This study aimed to investigate whether hemodynamic status before SBT contributed to the heterogeneous outcomes associated with SBT in acute critically ill patients.Methods: We obtained data from patients with metabolic acidosis from the Medical Information Mart for Intensive Care (MIMIC)-III database. Propensity score matching (PSM) was applied to match the SBT group with the control group. Logistic regression and Cox regression were used to analyze a composite of newly “developed or exacerbated organ dysfunction” (d/eOD) within 7 days of ICU admission and 28-day mortality associated with SBT for metabolic acidosis.Results: A total of 1,765 patients with metabolic acidosis were enrolled, and 332 pairs obtained by PSM were applied to the final analyses in the study. An increased incidence of newly d/eOD was observed in the SB group compared with the control group (54.8 vs. 44.6%, p < 0.01). Multivariable logistic regression indicated that the adjusted OR of SBT for this composite outcome was no longer significant [OR (95% CI): 1.39 (0.9, 1.85); p = 0.164]. This effect of SBT did not change with the quintiles stratified by pH. Interestingly, SBT was associated with an increased risk of the composite of newly d/eOD in the subgroup of patients with worsening hemodynamics before SBT [adjusted OR (95% CI): 3.6 (1.84, 7.22), p < 0.001]. Moreover, the risk potential for this composite of outcomes was significantly increased in patients characterized by both worsening [adjusted OR (95% CI): 2.91 (1.54, 5.47), p < 0.001] and unchanged hemodynamics [adjusted OR (95% CI): 1.94 (1.01, 3.72), p = 0.046] compared to patients with improved hemodynamics before SBT. Our study failed to demonstrate an association between SBT and 28-day mortality in acute critically ill patients with metabolic acidosis.Conclusions: Our findings did not demonstrate an association between SBT and outcomes in critically ill patients with metabolic acidosis. However, patients with either worsening or unchanged hemodynamic status in initial resuscitation had a significantly higher risk potential of newly d/eOD subsequent to SBT.

Profound Metabolic Acidosis due to Metformin Intoxication Requiring Dialysis

Metformin-associated lactic acidosis (MALA) is a rare but life-threatening condition with often high mortality rates. Despite this, metformin continues to be one of the most commonly prescribed antihyperglycemic agents in the market. We present a unique case of a 61-year-old female with severe acidosis of pH = 6.72 and lactic acid of 26 mmol/L who presented obtunded after ingestion of an unknown amount of metformin. She was subsequently intubated, became hypotensive, and was initiated on vasopressors. She was swiftly started on a combination of intermittent hemodialysis (IHD) and bicarbonate therapy 7 hours after admission followed by continuous renal replacement therapy (CRRT) as she became more hemodynamically unstable. The patient’s renal function improved, and she was discharged 7 days after admission with favorable sequelae. Dialysis is often reported in cases of severe MALA; however, it remains unclear how quickly dialysis should be initiated. This case aims to explore the benefits of quick initiation of extracorporeal measures in the forms of IHD and CRRT with concurrent bicarbonate supplementation. Furthermore, this case demonstrates the importance of clinical suspicion in metabolic acidosis in a patient on metformin therapy.

Relationship between mortality and use of sodium bicarbonate at the time of dialysis initiation: a prospective observational study

Background Patients with chronic kidney disease often experience metabolic acidosis. Whether oral sodium bicarbonate can reduce mortality in patients with metabolic acidosis has been debated for years. Hence, this study was conducted to evaluate the utility of sodium bicarbonate in patients who will undergo dialysis therapy. In this study, we investigated the effect of oral sodium bicarbonate therapy on mortality in patients with end-stage kidney disease (ESKD) initiated on dialysis therapy. Methods We conducted an observational study of patients when they started dialysis therapy. There were 17 centres participating in the Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis. Data were available on patients’ sex, age, use of sodium bicarbonate, drug history, medical history, vital data, and laboratory data. We investigated whether patients on oral sodium bicarbonate for more than three months before dialysis initiation had a better prognosis than those without sodium bicarbonate therapy. The primary outcome was defined as all-cause mortality. Results The study included 1524 patients with chronic kidney disease who initiated dialysis between October 2011 and September 2013. Among them, 1030 were men and 492 women, with a mean age of 67.5 ± 13.1 years. Of these, 677 used sodium bicarbonate and 845 did not; 13.6% of the patients in the former group and 21.2% of those in the latter group died by March 2015 (p < 0.001). Even after adjusting for various factors, the use of sodium bicarbonate independently reduced mortality (p < 0.001). Conclusions The use of oral sodium bicarbonate at the time of dialysis initiation significantly reduced all-cause mortality in patients undergoing dialysis therapy.

The effect of sodium bicarbonate administration on renal function: A systematic review and meta-analysis of clinical trials

Background Metabolic acidosis is a prevalent condition in patients with chronic kidney disease (CKD). Although sodium bicarbonate is extensively used for management of metabolic acidosis, its efficacy has not been summarized in previous review studies. Objective To conduct a systematic review and meta-analysis to estimate the overall effects of sodium bicarbonate on indices of renal function in patients with CKD. Methods A systematic literature search was carried out through the Medline, Web of Science and Scopus databases, up to July 2020. Studies that reported the effects of oral sodium bicarbonate administration on renal function were included. Blood urea nitrogen (BUN), serum creatinine, glomerular filtration rate (GFR), and creatinine clearance were defined as renal function indices. A random-effects model was used to calculate the overall effect and reported as weighted mean difference (WMD). Results Thirteen studies were included in this systematic review and meta-analysis. A beneficial effect of sodium bicarbonate was observed on BUN (WMD: − 8.63 mg/dL; 95% CI: -11.08, -6.19), serum creatinine (WMD: -0.19 mg/dL; 95% CI: -0.36, -0.02), GFR (WMD: 0.75 ml/min/1.73 m2; 95% CI: 0.14, 1.35), and creatinine clearance (WMD: 4.82 mL/min; 95% CI: 2.68, 6.96). There was no between study heterogeneity for all renal function indices. Also, no publication bias was observed in this study. Conclusion This systematic review and meta-analysis showed that sodium bicarbonate supplementation could increase GFR and creatinine clearance and decrease BUN and creatinine. Therefore, sodium bicarbonate therapy may efficacious in ameliorating the progression of CKD.

Relationship Between Mortality and Use of Sodium Bicarbonate at the Time of Dialysis Initiation: A Prospective Observational Study

Background Patients with chronic kidney disease often experience metabolic acidosis. Whether oral sodium bicarbonate can reduce mortality in patients with metabolic acidosis has been debated for years. Hence, this study was conducted to evaluate the utility of sodium bicarbonate in patients who will undergo dialysis therapy. In this study, we investigated the effect of oral sodium bicarbonate therapy on mortality in patients with end-stage kidney disease (ESKD) initiated on dialysis therapy. Methods We conducted an observational study of patients when they started dialysis therapy. There were 17 centres participating in the Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis. Data were available on patients’ sex, age, use of sodium bicarbonate, drug history, medical history, vital data, and laboratory data. We investigated whether patients on oral sodium bicarbonate for more than three months before dialysis initiation had a better prognosis than those without sodium bicarbonate therapy. The primary outcome was defined as all-cause mortality. Results The study included 1524 patients with chronic kidney disease who initiated dialysis between October 2011 and September 2013. Among them, 1030 were men and 492 women, with a mean age of 67.5 ± 13.1 years. Of these, 677 used sodium bicarbonate and 845 did not; 13.6% of the patients in the former group and 21.2% of those in the latter group died by March 2015 (p < 0.001). Even after adjusting for various factors, the use of sodium bicarbonate independently reduced mortality (p < 0.001). Conclusions The use of oral sodium bicarbonate at the time of dialysis initiation significantly reduced all-cause mortality in patients undergoing dialysis therapy.

Risk Potential for Organ Dysfunction Associated with Sodium Bicarbonate Therapy (SBT) in Critically Ill Patients with Hemodynamic Worsening

Background: The role of sodium bicarbonate therapy (SBT) remains controversial. This study aimed to investigate whether hemodynamic status before SBT contributed to the heterogeneous outcomes associated with SBT in acute critically ill patients.Methods: We obtained data from patients with metabolic acidosis from the Medical Information Mart for Intensive Care (MIMIC)-III database. Propensity score matching (PSM) was applied to match the SBT group with the control group. Logistic regression and Cox regression were used to analyze a composite of newly “developed or exacerbated organ dysfunction” (d/eOD) within 7 days of ICU admission and 28-day mortality associated with SBT for metabolic acidosis.Results: A total of 1765 patients with metabolic acidosis were enrolled, and 332 pairs obtained by PSM were applied to the final analyses in the study. An increased incidence of newly d/eOD was observed in the SB group compared with the control group (54.8% vs 44.6%, p<0.01). Multivariable logistic regression indicated that the adjusted OR of SBT for this composite outcome was no longer significant [OR (95% CI): 1.39 (0.9, 1.85); p=0.164]. This effect of SBT did not change with the quintiles stratified by pH. Interestingly, SBT was associated with an increased risk of the composite of newly d/eOD in the subgroup of patients with worsening hemodynamics before SBT [adjusted OR (95% CI): 3.6 (1.84, 7.22), p< 0.001]. Moreover, the risk potential for this composite of outcomes was significantly increased in patients characterized by both worsening [adjusted OR (95% CI): 2.91 (1.54, 5.47), p< 0.001] and unchanged hemodynamics [adjusted OR (95% CI): 1.94 (1.01, 3.72), p=0.046) compared to patients with improved hemodynamics before SBT. Our study failed to demonstrate an association between SBT and 28-day mortality in acute critically ill patients with metabolic acidosis.Conclusions: Our findings suggested that SBT for metabolic acidosis was associated with an increased risk potential for subsequent d/eOD, while the hemodynamic status remained unstable during the acute phase of critical illness.

Incidence and management of metabolic acidosis with sodium bicarbonate in the ICU: An international observational study

Background Metabolic acidosis is a major complication of critical illness. However, its current epidemiology and its treatment with sodium bicarbonate given to correct metabolic acidosis in the ICU are poorly understood. Method This was an international retrospective observational study in 18 ICUs in Australia, Japan, and Taiwan. Adult patients were consecutively screened, and those with early metabolic acidosis (pH < 7.3 and a Base Excess < –4 mEq/L, within 24-h of ICU admission) were included. Screening continued until 10 patients who received and 10 patients who did not receive sodium bicarbonate in the first 24 h (early bicarbonate therapy) were included at each site. The primary outcome was ICU mortality, and the association between sodium bicarbonate and the clinical outcomes were assessed using regression analysis with generalized linear mixed model. Results We screened 9437 patients. Of these, 1292 had early metabolic acidosis (14.0%). Early sodium bicarbonate was given to 18.0% (233/1292) of these patients. Dosing, physiological, and clinical outcome data were assessed in 360 patients. The median dose of sodium bicarbonate in the first 24 h was 110 mmol, which was not correlated with bodyweight or the severity of metabolic acidosis. Patients who received early sodium bicarbonate had higher APACHE III scores, lower pH, lower base excess, lower PaCO2, and a higher lactate and received higher doses of vasopressors. After adjusting for confounders, the early administration of sodium bicarbonate was associated with an adjusted odds ratio (aOR) of 0.85 (95% CI, 0.44 to 1.62) for ICU mortality. In patients with vasopressor dependency, early sodium bicarbonate was associated with higher mean arterial pressure at 6 h and an aOR of 0.52 (95% CI, 0.22 to 1.19) for ICU mortality. Conclusions Early metabolic acidosis is common in critically ill patients. Early sodium bicarbonate is administered by clinicians to more severely ill patients but without correction for weight or acidosis severity. Bicarbonate therapy in acidotic vasopressor-dependent patients may be beneficial and warrants further investigation.

Hypocalcemia of the newborn due to red blood cell transfusion: Case report

Introduction: Hypocalcemia in preterm infants could occurs as early or late. Causes of late onset of hypocalcaemia: maternal vitamin D deficiency, metabolic syndromes, congenital abnormalities, iatrogenic (transfusion, bicarbonate therapy, phototherapy, antibiotics). Case report: The authors describe the occurrence of late hypocalcemia following transfusion of erythrocytes to the second newborn from a twin pregnancy born prematurely in the 32/33 week of gestation. Mother is diabetic and has hypertension, edema, hypothyroidism, and preeclampsia during pregnancy. Due to the detected pyelectasis in newborn, prophylactic use of cephalexin was introduced. At the end of the first month of life, anemia appear indicating a transfusion. The infant received 50 ml an O+ leukodepleted RBC transfusion. Immediately after transfusion was completed, there is a short-term deterioration of the general condition. Cyanosis, stiffness, trismus, and bradycardia appear within a few seconds. DAT was negative, bilirubin in the reference range. After transfusion, laboratory, echosonographic examination, neurological examination, EEG and ECG showed normal results. It was concluded that the adverse reaction was probably caused by transfusion. Conclusion: In preterm infants, hypocalcaemia may occur during transfusion due to citrate overload. Children of diabetic mothers, on antibiotic and photo therapy are at higher risk of developing hypocalcemia. Future studies should evaluate incidence rate of adverse transfusion reactions in newborns.