For decades, emergency teams have routinely administered sodium bicarbonate during cardiac arrest to counter the severe metabolic acidosis that accompanies prolonged resuscitation. This landmark trial directly challenges whether that practice translates into meaningful survival benefit — a question with significant implications for how millions of cardiac arrest cases are managed annually in hospital settings worldwide.
Published in JAMA, this multicenter randomized controlled trial examined whether intravenous sodium bicarbonate given during in-hospital cardiac arrest improves the rate of sustained return of spontaneous circulation (ROSC) compared to standard care without bicarbonate. The trial enrolled a substantial patient cohort across multiple hospital sites, allowing for statistical power sufficient to detect clinically meaningful differences. The primary endpoint — sustained ROSC — showed no statistically significant improvement in the bicarbonate group, with secondary outcomes including survival to discharge and neurological function following a similar pattern of non-superiority.
This finding carries considerable weight in the resuscitation medicine landscape. The theoretical rationale for bicarbonate — correcting acidemia to restore cardiac contractility and improve responsiveness to vasopressors — has never been robustly validated in controlled human trials, despite widespread use. This trial joins a growing body of evidence suggesting that many longstanding resuscitation adjuncts, adopted based on physiological plausibility rather than outcomes data, fail to demonstrate survival benefit when rigorously tested. The result is broadly consistent with prior observational data and smaller trials that raised similar doubts. Key limitations include the inherent difficulty of standardizing resuscitation protocols across sites and the challenge of blinding emergency interventions. Nonetheless, as a randomized design in the acute care setting, this represents some of the strongest available evidence yet that routine bicarbonate administration during in-hospital cardiac arrest may not improve patient outcomes.