Bicarb drips are a myth. Until they're not.

[RustedFox]

Unggggh.


I have three intensivists at my main shop; none of which can agree as to when to start a bicarb drip in the setting of metabolic acidosis.

Its especially funny when they hand-off care.

One note:

"Patient has mild metabolic acidosis and acute on chronic renal failure, plan to continue gentle rehydration and pursue goals."

*hand off, same day*

"Patient is profoundly acidotic and is in critical conditon, plan to initiate aggressive bicarbonate infusion. CC time 88 minutes."


This was a patient that I admitted to the ICU in acute renal failure with pH of 7.22.

Not 6.9.

Not 7.0.

...

Not even 7.1



"PROFOUNDLY ACIDOTIC OMG START BICARB DRIP ROFL LOLZ"


I hate my intensivists.

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[Tenk]

Forget bicarb, should just consult hospice for a pH that low.

 

[RustedFox]

Forget bicarb, should just consult hospice for a pH that low.

You reminded me of a hilarious story.

I was fresh out of residency. Working my first job. We had an internist... we will call her Dr. PissyPants.

Dr. PissyPants challenged a lot of admissions with "what we need is a hospice consult"

Even in the face of things like "Look: he is 85 years old, but he has pancreatitis and needs to be admitted. He still plays pickleball with his wife and crew at the beach club and robbledy robbledy robble."

Nevermind that. "HOSPICE!!!"

Dr. PissyPants retired one day. We all knew about it. Everyone. From ER to Radiology to ICU to Wound Care. She was kinda "hated" all over for her obstructionist tactics.

Dr. PissyPants was on her bicycle one day, and she got hit by a car. Simple pneumothorax, did not need the needle. Proximal humerus fracture. Couple'a rib fractures.

Admitted to our facility.

First thing I said to my charge RN was: "We need a hospice consult."

 

[Zebra Hunter]

Bicarb for metabolic acidosis? Lol. The way to treat metabolic acidosis is to fix the cause of the metabolic acidosis, not bicarb. Bicarb is essentially worthless in that situation. I’ll still never understand the obsession everyone in medicine, outside of the ER, has with giving bicarb.

“Got a DKA’er with a pH of 7.2 and a bicarb of 9, on insulin drip and given 2L LR, completely stable.”

“Have you given any bicarb yet?”

“No, I don’t give it unless pH <6.9 in DKA, and even that is probably a questionable practice completely devoid of evidence.”

“Well I think you should give it, that bicarb level is very low.”

“Nah.”

 

[njac]

I’ll still never understand the obsession everyone in medicine, outside of the ER, has with giving bicarb.

There are still plenty of EM physicians who just can’t leave that number alone.

“The number is out of range... must do something”

But thankfully we’ve done a better job with the younger physicians and they’re willing to hold off. The bicarb shortage has done wonderful things for our use in cardiac arrest.

 

[betamale]

Unggggh.


I have three intensivists at my main shop; none of which can agree as to when to start a bicarb drip in the setting of metabolic acidosis.

Its especially funny when they hand-off care.

One note:

"Patient has mild metabolic acidosis and acute on chronic renal failure, plan to continue gentle rehydration and pursue goals."

*hand off, same day*

"Patient is profoundly acidotic and is in critical conditon, plan to initiate aggressive bicarbonate infusion. CC time 88 minutes."


This was a patient that I admitted to the ICU in acute renal failure with pH of 7.22.

Not 6.9.

Not 7.0.

...

Not even 7.1



"PROFOUNDLY ACIDOTIC OMG START BICARB DRIP ROFL LOLZ"


I hate my intensivists.

I always give it as a push if I thinks it's worth it and especially if the K is high. I may use a drip if it's readily available, which is not, and use plasmalyte or LR for resus to avoid worsening the acidosis and AG.

CRF with profound acidosis should probably just get a Quinton that has that single lumen Cath on the middle (for infusions, resus) if CRRT/HD is easy to get at your hospital.

 

[DrGasPasser]

Bicarb for metabolic acidosis? Lol. The way to treat metabolic acidosis is to fix the cause of the metabolic acidosis, not bicarb. Bicarb is essentially worthless in that situation. I’ll still never understand the obsession everyone in medicine, outside of the ER, has with giving bicarb.

“Got a DKA’er with a pH of 7.2 and a bicarb of 9, on insulin drip and given 2L LR, completely stable.”

“Have you given any bicarb yet?”

“No, I don’t give it unless pH <6.9 in DKA, and even that is probably a questionable practice completely devoid of evidence.”

“Well I think you should give it, that bicarb level is very low.”

“Nah.”

I’d agree that bicarb for most AG acidosis is pointless with the possible exceptions of salicylate and toxic alcohol ingestions. On the other hand, bicarb for severe non-AG metabolic acidosis can be very reasonable in the correct circumstances (adequate minute ventilation, expected continued loss, etc.).

 

[Birdstrike]

So very little of what we do it proven to work, or not work, with certainty. What is unquestioned gospel today, is the blasphemy of the future; and blasphemy occasionally reverts to gospel again. In medical school you think medicine is 95% science and 5% art. You eventually come to realize it's more art than science, at times.

 

[thegenius]

I tend to avoid it...if the pH is < 7 I might or probably will depending on the stability of the patient.

It's a losing battle. Most docs I work with are older than me, been in the community longer than me, and routinely give bicarb. They don't get a flying-f$*! about evidence. Giving drips and pushes makes them feel good, and probably more easily justifies the admission or continued treatment in their eyes. I used to argue with them and they give me this weird look.

What's the point

 

[thegenius]

So very little of what we do it proven to work, or not work, with certainty. What is unquestioned gospel today, is the blasphemy of the future; and blasphemy occasionally reverts to gospel again. In medical school you think medicine is 95% science and 5% art. You eventually come to realize it's more art than science, at times.

Most of the time. Even when there's evidence, patients often don't fit the cohort...e.g. it's not applicable to that patient.

Most (95%) of all published research is false.

 

[deleted547339]

I think the big question is whether it’s anion gap or nonanion gap. Nagma probably should get bicarb. I don’t give any of my folks with an anion gap acidosis bicarb. There is some secondary outcome data saying bicarb may help in anion gap acidosis if you have aki, but I’m skeptical. I never start it in that setting, but if one of my partners starts it, I’ll rarely stop it.

Also, regarding the “severe” acidosis with a ph of 7.2 - it could be that the intensivist is trying to be colorful in his or her description to justify billing, but it could also be that they have a profound acidosis without a profound acedemia (I.e. they have a very low bicarb, but they have adequately compensated with their minute ventilation).

 

[RustedFox]

I think the big question is whether it’s anion gap or nonanion gap. Nagma probably should get bicarb. I don’t give any of my folks with an anion gap acidosis bicarb. There is some secondary outcome data saying bicarb may help in anion gap acidosis if you have aki, but I’m skeptical. I never start it in that setting, but if one of my partners starts it, I’ll rarely stop it.

Also, regarding the “severe” acidosis with a ph of 7.2 - it could be that the intensivist is trying to be colorful in his or her description to justify billing, but it could also be that they have a profound acidosis without a profound acedemia (I.e. they have a very low bicarb, but they have adequately compensated with their minute ventilation).

1. I value your posts. Thank you. If I remember, you're either a CC fellow or done with fellowship and are out their doing EM/CC somewhere.

2. "it could also be that they have a profound acidosis without a profound acidemia" - I even thought about this. Patient's HCO3 was 19. Sure, that's low, but its not that low. I've probably hit a bicarb of 19 during an epic hangover (which I thankfully have not had in a long, long time). I don't regularly do the black math that is the ABG compensation rules (I know its not hard math, I kid) - but I was wholly underwhelmed with the degree of illness the patient exhibited.

 

[Groove]

In general, I give bicarb when ph < 7 and/or ARF/AKI present. I sometimes give it during futile codes when I'm "throwing the kitchen sink" so to speak. I don't claim that it's evidence based but there is some limited evidence for the first two examples. I like a bit of voodoo.

 

[Porfirio]

Kitchen sink or toxicology reasons - I don’t have time for Voodoo, let someone else with time practice voodoo.

 

[deleted859535]

In general, I give bicarb when ph < 7 and/or ARF/AKI present. I sometimes give it during futile codes when I'm "throwing the kitchen sink" so to speak. I don't claim that it's evidence based but there is some limited evidence for the first two examples. I like a bit of voodoo.

Seconded on severe acidosis (DKA or otherwise at or under 6.9 as I was once taught) and in kitchen sink codes. Otherwise, unless for toxicologic reasons, I don't touch the stuff.

 

[deleted547339]

1. I value your posts. Thank you. If I remember, you're either a CC fellow or done with fellowship and are out their doing EM/CC somewhere.

2. "it could also be that they have a profound acidosis without a profound acidemia" - I even thought about this. Patient's HCO3 was 19. Sure, that's low, but its not that low. I've probably hit a bicarb of 19 during an epic hangover (which I thankfully have not had in a long, long time). I don't regularly do the black math that is the ABG compensation rules (I know its not hard math, I kid) - but I was wholly underwhelmed with the degree of illness the patient exhibited.

1. Yea. I attend in an academic MICU now. The times, they are a changin. Thanks.

2. Sounds like you either 1) have an alarmist intensivist which makes everyone down to the unit secretary crazy, every patient with a fever gets panscanned, cultured, mero and lizeolid as well as an ID consult. They are the worst. You sign out your patients to them to come back and hear “everyone got so sick!?!?” or “I think he was a lot sicker than you thought”. It gets real awkward. Same when they admit someone to you - yea, we’re going to cancel the mri, cards consult, echo antifungals and we’re definitely not doing a bronch. We’re giving then rocephin and azithro and a tincture of time because that’s all you need for CAP. Chill.....(sorry - I had some people like this in fellowship) Or 2) you have an intensivist who is getting colorful with their billing.

If I have a bicarb of 19, I don’t even mention it in my icu notes (which are admittedly sparse) other than to say “bicarb improving” in passing. Bicarb drops to 19 and it goes unnoticed. Agreed, if I go for a long run (and by long, I mean like 2 miles), you probably can drop your bicarb that low.

 

[RustedFox]

Sounds like you either 1) have an alarmist intensivist which makes everyone down to the unit secretary crazy, every patient with a fever gets panscanned, cultured, mero and lizeolid as well as an ID consult. They are the worst. You sign out your patients to them to come back and hear “everyone got so sick!?!?” or “I think he was a lot sicker than you thought”. It gets real awkward. Same when they admit someone to you - yea, we’re going to cancel the mri, cards consult, echo antifungals and we’re definitely not doing a bronch. We’re giving then rocephin and azithro and a tincture of time because that’s all you need for CAP. Chill.....(sorry - I had some people like this in fellowship) Or 2) you have an intensivist who is getting colorful with their billing.

If I have a bicarb of 19, I don’t even mention it in my icu notes (which are admittedly sparse) other than to say “bicarb improving” in passing. Bicarb drops to 19 and it goes unnoticed. Agreed, if I go for a long run (and by long, I mean like 2 miles), you probably can drop your bicarb that low.

It gets crazier between this group of three intensivists. The one guy who I have now known for 7 years is dual boarded in Pulm/CC and sleep medicine. I saw him in the office once because (yep; I sleepwalk - and it has gotten scary). After discussing somnambulism and laughing at how I felt that my baseball cap was an appropriate bowl for tortilla chips and salsa that night (yep, lost that hat), the discussion took a turn:

RF: "Hey, your new partner needs to learn a bit about collegiality. He cops a bad attitude every time I call him for an ICU admission (which I have to do, as per our by-laws, for every ICU admit) and the patient hasn't already been scoped by GI/ENT/Whatever and there aren't repeat labs already drawn.

CC: "Oh yeah, I know. He thinks this is freaking derm practice. Let me guess, he says things like - 'I trained at XXX, this would never fly there.'."

RF: "Yep. Seems he hasn't figured out that this isn't [academic ivory tower] and that he needs to go do some critical care."

CC: "Yeah, we've had this talk with him a few times now. The ICU nurses are ready to murder him, too."

-

This was the same guy that threw me under the bus in the chart by writing "I don't know how the patient was discharged with a bicarb of 19 for some reason" for a DKA bounceback who signed out AMA.

You don't know how ? Okay; apparently you can't read.