Alkali Therapies


  • sodium bicarbonate
  • THAM
  • Carbicarb
  • Dichloroacetate
  • Dialysis / hemofiltration


  • 8.4% and 4.2% solution
  • hyperosmolar
  • generates high CO2
  • used to treat a metabolic acidosis if pH < 7.1 (controversial)
  • improves vasopressor responsiveness
  • may have role in decreasing contrast nephropathy
  • adverse effects: paradoxical acidosis in the presence of low output, hypokalaemia, phlebitis


  • Tris-hydroxymethyl aminomethane (THAM)
  • commercially available weak alkali that buffers H+ ions
  • buffering not associated with a CO2 rise
  • adverse effects: hyperkalaemia, hypoglycaemia, extravasation necrosis, hepatic dysfunction


  • equimolar combination of sodium carbonate and sodium bicarbonate
  • generates a smaller rise in CO2 than sodium bicarbonate
  • more consistently increases intracellular pH
  • inconsistent effects on haemodynamics
  • not commonly used clinically


  • works by stimulating the pyruvate dehydrogenase complex which regulates the entry of pyruvate into tricarboxylic acid cycle
  • increases pH
  • decreases lactate
  • RCTs have found no benefit in haemodynamics or patient outcome


  • peritoneal dialysis effective at removing lactate
  • bicarbonate-buffered haemofiltration is ineffective
  • avoid lactate based buffers in those who with lactate acidosis or liver disease

References and Links


Journal articles

  • Gehlbach BK, Schmidt GA. Bench-to-bedside review: treating acid-base abnormalities in the intensive care unit – the role of buffers. Crit Care. 2004 Aug;8(4):259-65. PMC522834.
  • Hoste EA, Colpaert K, Vanholder RC, Lameire NH, De Waele JJ, Blot SI, Colardyn FA. Sodium bicarbonate versus THAM in ICU patients with mild metabolic acidosis. J Nephrol. 2005 May-Jun;18(3):303-7. PMID: 16013019.
  • Kraut JA, Kurtz I. Use of base in the treatment of severe acidemic states. Am J Kidney Dis. 2001 Oct;38(4):703-27. PubMed PMID: 11576874.
  • Morgan TJ. The meaning of acid-base abnormalities in the intensive care unit: part III — effects of fluid administration. Crit Care. 2005 Apr;9(2):204-11. PMC1175908.
  • Naka T, Bellomo R. Bench-to-bedside review: treating acid-base abnormalities in the intensive care unit–the role of renal replacement therapy. Crit Care. 2004 Apr;8(2):108-14. PMC420038.

CCC 700 6

Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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