Sodium Bicarbonate for Critically Ill Adults with Metabolic Acidosis and Shock
New England Journal of Medicine, 2026 · Pragmatic adaptive double-blind randomized trial in 55 ICUs, 500 patients
What the trial found
The primary outcome occurred in 40.2% versus 39.4% (adjusted difference 1.2 percentage points, 95% CI −7.1 to 9.4; P=.78). RRT use was 16.8% versus 20.9%, with a CI including no difference.
Current guideline position
This trial must be interpreted alongside indication-specific guidance; its result alone does not establish a universal treatment policy.
Clinical interpretation
No demonstrated major-kidney-event benefit in this population. Do not extrapolate the RRT reduction in BICARICU-2 to all patients with metabolic acidosis receiving vasopressors.
Limitations
Differential diagnosis (GOLD MARK vs HARDCARP), toxic alcohol osmolar gaps, Urine Anion Gap, and current sodium bicarbonate evidence including BICAR-ICU and BICARICU-2.
Stepwise 6-step interpretation algorithm, compensation formulas, albumin-corrected anion gap, delta ratio, and Stewart physicochemical (SID) principles.
Sepsis-AKI microcirculatory decoupling, KDIGO staging, Furosemide Stress Test (FST), urine microscopy, and the AEIOU dialysis threshold framework.
The subset of sepsis with profound circulatory and cellular/metabolic abnormality — clinically identified by a vasopressor requirement to maintain MAP ≥ 65 mmHg plus lactate > 2 mmol/L despite adequate fluid resuscitation.