The Acid Base Series
Time for more discussion of acid-base, a subject you know i obsess about.
Keith Corl's Email
By now I'm sure you've seen the work from Jaber's group on using bicarb in critically ill academic patients. Obviously there are limitations to the trial, not the least of them a negative primary outcome. And while the study wasn't powered to look a 28 day mortality or 7 day organ failure in those with a AKIN score of 2-3 I am sure many will take this positive secondary finding and run with it.
My biggest criticism was that they didn't break the study down into patients with anion gap metabolic acidosis (AGMA) vs. non-anion gap metabolic acidosis (NAGMA). I'm a big fan of your acid base pods and tend to agree with your take and the Forsythe paper and don't give bicarb to patients with an AGMA. So I went ahead and emailed Jaber and he got back to me. He told me that “90% of the patients enrolled were hyperlactatemic.” Moreover, most GI and renal patients with base loss were excluded b.c. bicarb was considered standard care, therefore the “large majority” had an AGMA. Interesting, now I'm second guessing myself and wondering if I should consider bicarb in AKIN patients with a AGMA.
I'm interested to hear your thoughts. I think it would make a great pod or a topic for Josh or Rory.
I hope all is well,
then I bring on Dr. David Story to discuss acid base and a set of posts by Jon-Emile Kenny.
Professor David Story
Jon-Emile Kenny Lactate Debate Posts
go to acidbase.org and use their analyzer to truly understand the quantitative approach
More Stuff to Read
Intracellular pH always decreases with sodium bicarb (See Table I)
Bicarb administration causes decreased ICal
If you control CO2 and Calcium, then it works (Animal Study-Anesthesiology 2014;120:926)
Now on to the Podcast…
- EMCrit 289 – Ketamine Only Intubation Paper with Brian Driver - January 12, 2021
- EMCrit 288 – Neurogenic Shock & Should we be Using Vasopressors for Hemorrhagic Shock? - December 29, 2020
- EMCrit 287 – Thoracotomy Masterclass with Dennis Kim - December 10, 2020