BICARICU-2 Trial

In the BICARICU-2 trial, critically ill patients with severe metabolic acidemia (pH ≤ 7.20, bicarbonate ≤ 20 mEq/L, PaCO₂ ≤ 45 mm Hg) and moderate to severe acute kidney injury (AKI stage 2–3 by KDIGO) admitted to 43 French ICUs were randomized to receive intravenous sodium bicarbonate infusion targeting arterial pH ≥ 7.30 (intervention) or no bicarbonate therapy with standard care (comparison). The primary outcome was 90-day all-cause mortality, with secondary outcomes including mortality at 28 and 180 days, renal replacement therapy (RRT) use and timing, organ support duration, and ICU or hospital stay. The main results showed no mortality difference between groups (62.1% vs 61.7%), but sodium bicarbonate was associated with a lower rate and delayed initiation of RRT (35% vs 50%, median 30.9 h vs 15.5 h). The conclusion was that intravenous sodium bicarbonate did not improve survival but appeared safe and may reduce or postpone the need for RRT in severe acidemia with AKI.