Table 2.

Summary of Clinical Scenarios and Recommendations

Clinical Scenario	Recommendation	Strength of Recommendation	Comments/Caveats
Lactic acidosis and circulatory shock	Routine use of bicarbonate supplementation is not recommended	B	There may be role for sodium bicarbonate infusion after initial resuscitation in patients with acute kidney injury and pH < 7.20.
Cardiac arrest	Routine use of bicarbonate supplementation is not recommended except in select cases (e.g., tricyclic antidepressant toxicity or hyperkalemia)	B	Bicarbonate administration is still recommended in sodium channel blockade toxicity, hyperkalemia. Limited trials completed in undifferentiated cardiac arrest, timing may be an important variable, requires more research.
DKA	Sodium bicarbonate therapy in initial resuscitation or subsequent phases is not recommended	B	May potentially be harmful in pediatric patients due to increased cerebral edema. Data for or against use in DKA with severe acidosis pH < 7.0 and hyperkalemia are lacking but is still recommended by some professional societies.
Rhabdomyolysis	There is no benefit to bicarbonate to alkalinize urine.	A	Fluid resuscitation is the priority. No randomized trials have been completed to specify fluid type during initial resuscitation.
NAGMA	Sodium bicarbonate supplementation is recommended in severe NAGMA	B	There are limited randomized controlled trials, but strong physiologic rationale for use of bicarbonate in NAGMA.

DKA = Diabetic ketoacidosis; NAGMA = non-anion gap metabolic acidosis.