A patient in septic shock from faecal peritonitis has pH 7.08, PaCO2 30 mmHg, HCO3 8 mEq/L and lactate 9 mmol/L despite ongoing resuscitation. According to current sepsis guidance, what is indicated regarding sodium bicarbonate?
- A Contraindicated in lactic acidosis regardless of severity
- B May be considered once pH falls to 7.2 or below ✓
- C Indicated only when the anion gap is normal
- D Indicated whenever the base deficit exceeds 5 mEq/L
Correct answer: B. May be considered once pH falls to 7.2 or below
Explanation
Current sepsis guidelines suggest considering IV sodium bicarbonate in patients with metabolic acidaemia and pH of 7.2 or less who remain hypoperfused despite optimised ventilation and resuscitation, aiming to improve haemodynamics and vasopressor responsiveness. Bicarbonate is not withheld purely because the cause is lactic acidosis, nor is a normal anion gap a trigger, since hyperchloraemic acidosis responds poorly and may worsen with more chloride load. Above pH 7.2 evidence shows no haemodynamic benefit.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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