Sodium Bicarb in Cardiac Arrest

Some baked-in practices in medicine don't hold up to closer inspection. This episode of EMRA*Cast turns attention to the use of sodium bicarbonate in cardiac arrest. 

Overview
EMRA*Cast host Matt Dillon, MD, (@mdmd_8889) recently spoke with clinical ED pharmacist Mike Perza, PharmD, BCPS, (@pillpushermike) and future EMRA*Cast host, PGY-4 Dustin Slagle, MD, regarding sodium bicarbonate use during cardiac arrest and why you might want to think twice.

Take-Home Points

• Bicarbonate use is still relatively common during cardiac arrest.
• Although there are various indications for bicarb use, the evidence has not proven it to be beneficial in cardiac arrest.
• Language in ACLS guidelines continues to move away from the use of bicarb, and the AHA “recommends against the routine use.”
• Multiple retrospective studies, RCTs, and meta-analyses have failed to show improved outcomes.
• The often-cited study that does purport a benefit has been controversial due to improper statistical application.
• There exist multiple barriers to withholding bicarb, which include cultural and situational biases.

Resources

• Ahn S, Kim YJ, Sohn CH, et al. Sodium bicarbonate on severe metabolic acidosis during prolonged cardiopulmonary resuscitation: a double-blind, randomized, placebo-controlled pilot study. J Thorac Dis. 2018;10(4):2295-2302. 
• Kawano T, Grunau B, Scheuermeyer FX, et al. Prehospital sodium bicarbonate use could worsen long term survival with favorable neurological recovery among patients with out-of-hospital cardiac arrest. Resuscitation. 2017;119:63-69. doi:10.1016/j.resuscitation.2017.08.008
• Vukmir RB, Katz L. Sodium Bicarbonate Study Group. Sodium bicarbonate improves outcome in prolonged prehospital cardiac arrest. Am J Emerg Med. 2006;24(2):156-161. 
• Rebel EM Article Review. Effectiveness of Sodium Bicarbonate Administration on Mortality in Cardiac Arrest Patients: A Systematic Review and Meta-Analysis.