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Effect of Perioperative Sodium Bicarbonate Administration on Renal Function Following Cardiac Surgery for Infective Endocarditis: a Randomized, Placebo-Controlled Trial
Cho JS, Shim J, Kang S, et al. Crit Care. 2017;21:3.
Study Question: Does perioperative sodium bicarbonate during cardiac surgery with cardiopulmonary bypass (CPB) prevent post-operative renal dysfunction for patients with infective endocarditis (IE)?
Study Description: This prospective, placebo-controlled trial randomized adults with IE scheduled for valvular heart surgery to receive perioperative sodium bicarbonate or placebo. Patients were randomized in a 1:1 fashion to receive sodium bicarbonate 154 mEq/L with a 0.5 mmol/kg loading dose over 1 hour, followed by a continuous infusion of 0.15 mmol/kg/hr for 23 hours or 0.9% sodium chloride at the equivalent volume. Standardized anesthetic care was provided to both groups. The primary outcome was evaluating the differences in peak serum creatinine (SCr) levels during the first 48 hours post-operatively.
Results: A total of 70 patients were enrolled with IE definitively confirmed in 64 patients (32 in each group). Baseline demographics were comparable between groups except for the control group having a higher incidence of thrombocytopenia < 150,000 (11 vs. 3, p = 0.017) and anti-platelet usage prior to surgery (5 vs. 0, p = 0.02). The post-operative peak SCr within the 48 hours post-op period was not significantly different between groups (1.01 vs. 0.88 mg/dL, p = 0.474). However, the increase in SCr above baseline was significantly higher in the bicarbonate group on POD2 (0.21 vs. 0.06 mg/dL, p = 0.028) and POD5 (0.23 vs. 0.06 mg/dL, p = 0.017) with the corresponding eGFR being significantly lower in the bicarbonate group. There were no differences in the incidence of AKI according to the AKIN criteria.
Conclusion(s): Perioperative sodium bicarbonate during cardiac surgery with CPB does not prevent post-operative renal dysfunction.
Perspective: Previous investigations have examined renal protection with sodium bicarbonate in non-infected patients yielding conflicting findings. Patients with IE are exposed to prolonged use of nephrotoxic antimicrobials prior to surgery.
This is the first study to evaluate the use of perioperative sodium bicarbonate infusion and its impact on post-operative renal function in patients with IE undergoing cardiac surgery. Despite the theoretical benefits of sodium bicarbonate, post-operative SCr levels were higher in the sodium bicarbonate group, without affecting the incidence of AKI.