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These 2 papers challenge management dogmas in critical care that have persisted despite low-quality/absent evidence.
In particular, one explores the dogma, “bicarbonate improves ventricular contractility in severe metabolic acidosis,” with the following points:
-intracellular pH (which has a large impact on myocardial contractility) correlates poorly with blood gas pH
-many of the studies regarding bicarbonate in severe metabolic acidosis and hemodynamics are done on animal shock models
-two studies in patients with lactic acidosis showed increase in pH with bicarb administration without beneficial impact on hemodynamics (even in pts with pH < 7.1)
-bicarb administration is associated with hypernatremia, hypokalemia, and decreased ionized calcium levels
References
Hofmaenner DA, Singer M. Challenging management dogma where evidence is non-existent, weak or outdated. Intensive Care Med. 2022;48(5):548-558.
Hofmaenner DA, Singer M. Challenging management dogma where evidence is non-existent, weak, or outdated: part II. Intensive Care Med. 2024;50(11):1804-1813.