The BICARICU-2 trial investigated the use of sodium bicarbonate (NaHCO3) infusions for critically ill patients suffering from severe acidemia and Acute Kidney Injury (AKI), most often due to septic shock.

While the trial, which was likely underpowered, did not demonstrate a reduction in all-cause mortality, it yielded a significant and highly practical finding: NaHCO3 administration reduced the need for Renal Replacement Therapy (RRT) or dialysis.

This reduction in RRT mirrors the results of the earlier BICARICU-1 trial, creating a consistent signal of benefit despite the subjective nature of dialysis initiation.

Given the lack of apparent adverse events and this promising suggestion of reducing a resource-intensive and high-risk intervention like RRT, the BICARICU-2 results provide “good enough” justification for enhancing the current practice of NaHCO3 infusion for patients with severe acidemia (pH < 7.15) and AKI. Clinically, this means adopting a more consistent approach, potentially utilizing more concentrated NaHCO3 solutions. However, facilities must consult with their ICU PharmD, as the specific 4.2% NaHCO3 solutions used in the trial may require local mixing or compounding.

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