For decades, sodium bicarbonate has been routinely administered during cardiac arrest under the assumption that correcting metabolic acidosis would improve outcomes. This large randomized trial puts that assumption under rigorous scrutiny — and the results challenge a deeply embedded clinical habit.
The trial, published in JAMA, examined whether sodium bicarbonate given during in-hospital cardiac arrest improves return of spontaneous circulation (ROSC), overall survival, and survival with favorable neurological outcomes. Enrolling patients experiencing cardiac arrest in a hospital setting, the researchers compared bicarbonate administration against standard resuscitation care. Across the primary and secondary endpoints — including ROSC rates and neurologically intact survival — sodium bicarbonate failed to demonstrate a statistically significant benefit, suggesting the long-standing practice may offer little measurable value in this acute emergency context.
This finding fits within a growing body of evidence questioning alkalinizing therapies during cardiac arrest. The physiological rationale for bicarbonate — neutralizing the lactic acidosis that accompanies circulatory collapse — has always been theoretically compelling, yet clinical translation has proved elusive. Prior observational studies and smaller trials had already raised doubts, but this randomized design provides substantially stronger causal footing. Critically, the in-hospital setting distinguishes this cohort from out-of-hospital arrest populations, where resuscitation timelines and baseline patient characteristics differ markedly, limiting generalizability across all arrest scenarios.
From a clinical and public health perspective, the implications are meaningful: if bicarbonate confers no benefit, its routine use may represent unnecessary pharmacological burden with potential harms, including paradoxical intracellular acidosis and hyperosmolarity. For health-conscious adults and their families, this research underscores that resuscitation science continues to evolve, and that interventions once considered standard are being held to a higher evidentiary bar. This study reads as a potentially practice-changing contribution to emergency medicine, though replication across diverse hospital systems and arrest etiologies will be important.