#Epi 135 - SODa-BIC Trial: Sodium Bicarbonate for Metabolic Acidosis and Shock, with Prof. Ary Serpa Neto.

A patient in shock, on noradrenaline, with a pH of 7.22 and a base excess of minus 8. Do you give bicarbonate? Depending on which ICU you work in, the answer ranges from almost never to almost always.

In this episode of the eCritCare Podcast, Dr Swapnil Pawar is joined by Professor Ary Serpa Neto of Monash University, lead investigator of the SODa-BIC trial, published in the New England Journal of Medicine in 2026. SODa-BIC randomised 500 critically ill adults with metabolic acidosis receiving vasopressors, across 55 ICUs in seven countries, to sodium bicarbonate or placebo in a double-blind design.

In this conversation:

• Why SODa-BIC was needed after BICAR-ICU, and why it targeted earlier, less severe acidaemia
• Choosing pH below 7.30, base excess below minus 4 and vasopressor use as entry criteria
• Why MAKE30 was the primary outcome rather than mortality alone
• How you blind bicarbonate: 5% dextrose bags, unblinded and blinded investigators at every site
• Sample size, a blinded re-estimation, and what Ary would do differently with a win ratio
• The results: faster correction of acidosis but no difference in MAKE30, mortality or persistent renal dysfunction
• The 4% lower rate of renal replacement therapy, and why a little bicarbonate before a Vascath may be reasonable
• Cost, sustainability and low and middle income settings
• Waivers of consent, a five-hour intervention and data minimalism
• What comes next: MOSAIC, an individual patient data meta-analysis and SODa-BIC sub-studies

Read this episode on Substack: https://critcareedu.substack.com/p/soda-bic-trial-sodium-bicarbonate-metabolic-acidosis

Paper: Serpa Neto A, McNamara M, White K, et al. Sodium Bicarbonate for Critically Ill Adults with Metabolic Acidosis and Shock. N Engl J Med. 2026. doi:10.1056/NEJMoa2600526