Bicarbonate Therapy in Cardiogenic Shock with Severe Metabolic Acidosis

Introduction to Bicarbonate Therapy

• The American Academy of Pediatrics recommends that bicarbonate should only be given after effective ventilation has been established, as ventilation is needed to eliminate the excess CO2 produced 2

Clinical Considerations

• Bicarbonate therapy is not recommended for hypoperfusion-induced lactic acidemia when pH ≥ 7.15, according to the Surviving Sepsis Campaign guidelines 3
• The British Journal of Anaesthesia suggests that bicarbonate administration will worsen CO2 production and potentially exacerbate respiratory acidosis in a patient who cannot adequately ventilate 1

Management Priorities

• The American College of Cardiology is not mentioned, however, the British Journal of Anaesthesia recommends addressing the respiratory failure first by providing ventilatory support to correct the CO2 retention before any bicarbonate consideration 1
• Optimizing hemodynamics is crucial, which includes optimizing preload 3, inotropic support as needed 1, mechanical circulatory support if refractory 3, and addressing the underlying cardiac ischemia 3

Treatment Guidelines

• The Intensive Care Medicine journal suggests that bicarbonate should not be given to a patient with inadequate ventilation, as it is the most important contraindication in this case 2
• The initial dose of bicarbonate, if considered, should be 1-2 mEq/kg IV administered slowly, with careful monitoring of ionized calcium and avoidance of extreme alkalemia 2