Sodium Bicarbonate for In-Hospital Cardiac Arrest: A Randomized Clinical Trial.

Summary

In a 21-center, double-blind RCT of 779 adults with in-hospital cardiac arrest, sodium bicarbonate did not improve sustained return of spontaneous circulation compared with placebo. Thirty-day survival and favorable neurologic outcome were also not significantly different, while alkalosis and hypernatremia were more frequent with bicarbonate.

Key Findings

• Sustained ROSC: 39% with sodium bicarbonate vs 37% with placebo (RR 1.05; 95% CI 0.88–1.24).
• No significant differences in 30-day survival (12% vs 9.1%) or favorable neurologic outcome (8.1% vs 5.4%).
• Higher rates of post-arrest alkalosis and hypernatremia in the bicarbonate group.

Clinical Implications

Do not routinely administer sodium bicarbonate during in-hospital cardiac arrest; focus on high-value interventions (high-quality CPR, timely defibrillation, epinephrine) and reserve bicarbonate for specific indications (e.g., hyperkalemia, severe metabolic acidosis).

Limitations

• Excludes out-of-hospital cardiac arrest; generalizability limited to in-hospital settings.
• Subgroup analyses for specific metabolic derangements were not powered to detect small effects.

Future Directions

Clarify indications for targeted bicarbonate therapy (e.g., severe acidosis, hyperkalemia) during resuscitation and integrate trial findings into guideline updates and deimplementation strategies.