Acidemia has both harmful and beneficial biological effects. Sodium bicarbonate is generally ineffective in raising pH when ventilation is limited, as in patients with ARDS. Even when alkalinizing agents can correct the pH, evidence of efficacy is lacking. Thus, these treatments should not be considered standard therapy in patients with organic acidoses, such as lactic acidosis. Rather, attention should be directed toward correcting the underlying basis for the acidosis. Alternative buffer agents, such as tromethamine, offer potential advantages over sodium bicarbonate, but clinical trials in humans are lacking. Intravenous sodium bicarbonate may decrease the arterial [H+] when ventilation is not limited, but its effect on intra-cellular pH is unclear. Perhaps more importantly, no clinical benefit from sodium bicarbonate has been demonstrated in the setting of lactic or ketoacidosis, but volume overload, hyperosmolarity, and a decrease in ionized calcium are known to complicate its use.

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