Sodium Bicarbonate Fails to Improve Cardiac Arrest ROSC
Trial Overview and Context
Historically, clinicians often reconsider the utility of sodium bicarbonate cardiac arrest protocols during acute emergencies. Therefore, clinical teams frequently debate whether buffering severe acidosis during cardiopulmonary resuscitation improves patient survival. However, routine empirical alkalinization lacks strong evidence from modern blinded randomized trials. To resolve this uncertainty, the BIHCA trial evaluated intravenous sodium bicarbonate versus saline placebo in adult in-hospital cardiac arrest. Consequently, this landmark multicenter Danish study provides crucial data regarding resuscitation pharmacology.
Evidence on Sodium Bicarbonate Cardiac Arrest Resuscitation
Specifically, the trial enrolled 779 adult patients who suffered an in-hospital cardiac arrest and received epinephrine. Resuscitation teams administered either up to 100 mmol of intravenous sodium bicarbonate or matched placebo. The researchers selected sustained return of spontaneous circulation, or ROSC, as the primary clinical endpoint. Sustained ROSC required palpable pulses without chest compressions for at least twenty minutes. Ultimately, 39% of patients receiving sodium bicarbonate achieved sustained ROSC compared to 37% receiving placebo. Furthermore, the adjusted relative risk of 1.05 demonstrated no statistically significant difference between the two groups.
Secondary Clinical Outcomes and Safety Risks
In addition, investigators tracked 30-day survival and favorable neurological outcomes among all participants. At 30 days, 12% in the bicarbonate group survived compared with 9.1% in the placebo group. Similarly, favorable neurological function reached 8.1% with bicarbonate versus 5.4% with placebo. However, the study lacked statistical power for these secondary endpoints, and confidence intervals crossed unity. Meanwhile, the intervention triggered substantial biochemical disturbances among resuscitated patients. Sodium bicarbonate significantly increased rates of hypernatremia and metabolic alkalosis within the first 24 hours. Consequently, unguided administration poses definite physiological hazards without proven resuscitation benefit.
Clinical Practice Takeaways for Indian Hospitals
Currently, many intensive care units and emergency departments in India routinely use bicarbonate during prolonged arrests. Therefore, Indian resuscitation practitioners must align their resuscitation protocols with contemporary international evidence. The 2025 American Heart Association guidelines already advise against routine sodium bicarbonate administration. Instead, physicians should restrict bicarbonate use to specific indications like hyperkalemia or tricyclic antidepressant toxicity. In summary, high-quality chest compressions and rapid defibrillation remain the true cornerstones of successful resuscitation.
Frequently Asked Questions
Q1: Did sodium bicarbonate improve sustained ROSC in the BIHCA trial?
No, sodium bicarbonate did not significantly improve sustained ROSC compared to placebo in the trial. Specifically, ROSC occurred in 39% of bicarbonate recipients versus 37% of placebo recipients.
Q2: What adverse effects occurred with sodium bicarbonate during resuscitation?
Patients receiving sodium bicarbonate experienced substantially higher rates of hypernatremia and metabolic alkalosis. Furthermore, these metabolic derangements can impair tissue oxygen delivery and cellular function after resuscitation.
Q3: When should clinicians consider sodium bicarbonate during cardiac arrest?
Clinicians should avoid routine administration during standard cardiac arrest scenarios. However, physicians may consider bicarbonate for specific conditions, such as preexisting severe hyperkalemia or tricyclic antidepressant overdose.
References
- Maqsood MH et al. In adults with in-hospital cardiac arrest, sodium bicarbonate vs. placebo did not increase sustained ROSC rates. Ann Intern Med. 2026 Oct 06. doi: 10.7326/ANNALS-26-03498-JC. PMID: 42832811.
- Granfeldt A, Kirkegaard BL, Vallentin MF, et al. Sodium Bicarbonate for In-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2026;336(8):647-654. doi: 10.1001/jama.2026.10628.
- Couper K, Alenazi A, Gray J, et al. Adult Advanced Life Support: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025;152(16_suppl_2):S367-S434.
