The use of bicarbonate is a source of eternal disagreement. Bicarbonate has a shameful history of being abused in situations where it’s unhelpful (e.g. cardiac arrest). This has impugned its reputation, giving it an aura of ignorance and failure. Consequently, bicarbonate is underutilized in some situations where it might actually help. This is an open-label multicenter RCT involving 389 patients within 48 hours of ICU admission. Inclusion required the presence of metabolic acidosis (pH < 7.20, PaCO2 < 45 mM) plus either SOFA score >3 or lactate >2 mM (6). Exclusion criteria included ongoing loss of bicarbonate from the GI tract or kidneys (defined as volume loss >1500 ml/day or renal tubular acidosis), stage IV chronic kidney disease, ketoacidosis, or exogenous acid load

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