Sodium bicarbonate administration is associated with improved survival in asystolic and PEA Out-of-Hospital cardiac arrest



      Sodium bicarbonate (“bicarb”) administration in out-of-hospital cardiac arrest (OHCA) is intended to counteract acidosis, although there is limited clinical evidence to support its routine administration. We sought to analyze the association of bicarb with resuscitation outcomes in non-traumatic OHCA.


      Records were obtained from the 2019–2020 ESO Data Collaborative prehospital electronic health record database, spanning 1,322 agencies in 50 states. OHCAs with resuscitations lasting 5–40 minutes were stratified by presenting ECG rhythm (VF/VT, pulseless electrical activity (PEA), asystole) for analysis. The outcomes of any prehospital ROSC and survival to discharge were compared by bicarb status using propensity score matching and logistic regressions with/without adjustment.


      We analyzed 23,567 records, 6,663 (28.3 %) of which included bicarb administration. Most patients presented in asystole (67.4 %), followed by PEA (16.6 %), and VF/VT (15.1 %). In the propensity-matched cohort, ROSC was higher in the bicarb group for the asystole group (bicarb 10.6 % vs control 8.8 %; p = 0.013), without differences in the PEA or VF/VT groups. Survival was higher in the bicarb group for asystole (bicarb 3.3 % vs control 2.4 %; p = 0.020) and for PEA (bicarb 8.1 % vs control 5.4 %; p = 0.034), without differences in the VF/VT group. These results were consistent across adjusted/unadjusted logistic regression analyses: bicarb was associated with ROSC and survival in asystole [uOR (95 % CI): ROSC 1.23 (1.04–1.44), survival 1.40 (1.05–1.87)] and with survival in PEA (1.54 (1.03–2.31).


      Bicarb was associated with survival in non-shockable rhythms and ROSC in asystole. Findings from this observational study should be corroborated with prospective randomized work.
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        • Standards for Cardiopulmonary Resuscitation (CPR)
        • Emergency Cardiac Care (ECC)
        JAMA. 1974; 227: 837-866
        • Orchard C.H.
        • Kentish J.C.
        Effects of changes of pH on the contractile function of cardiac muscle.
        Am Physiol Soc. 1990; : C967-C981
        • Orchard C.H.
        • Cingolani H.E.
        Review article Acidosis and arrhythmias in cardiac muscle.
        J Physiol (Paris). 1994; : 1312-1319
        • Gerst P.H.
        • Fleming W.H.
        • Malm J.R.
        Increased Susceptibility of the Heart to Ventricular Fibrillation During Metabolic Acidosis.
        Circ Res. 1966; 19: 63-70
        • Schotola H.
        • Toischer K.
        • Popov A.F.
        • et al.
        Mild metabolic acidosis impairs the β-adrenergic response in isolated human failing myocardium.
        Crit Care. 2012; 16: 1-10
        • Marsh J.D.
        • Margolis T.I.
        • Kim D.
        Mechanism of diminished contractile response to catecholamines during acidosis.
        Am J Physiol Heart Circ Physiol. 1988; 254: H20-H27
        • Bar-Joseph G.
        • Abramson N.S.
        • Kelsey S.F.
        • Mashiach T.
        • Craig M.T.
        • Safar P.
        Improved resuscitation outcome in emergency medical systems with increased usage of sodium bicarbonate during cardiopulmonary resuscitation.
        Acta Anaesthesiol Scand. 2005; 49: 6-15
        • Vukmir R.B.
        • Katz L.
        Sodium bicarbonate improves outcome in prolonged prehospital cardiac arrest.
        Am J Emerg Med. 2006; 24: 156-161
        • Kim J.
        • Kim K.
        • Park J.
        • et al.
        Sodium bicarbonate administration during ongoing resuscitation is associated with increased return of spontaneous circulation.
        Am J Emerg Med. 2016; 34: 225-229
        • Chen Y.C.
        • Hung M.S.
        • Liu C.Y.
        • Hsiao C.T.
        • Yang Y.H.
        The association of emergency department administration of sodium bicarbonate after out of hospital cardiac arrest with outcomes.
        Am J Emerg Med. 2018; 36: 1998-2004
        • Wu K.H.
        • Chang C.Y.
        • Chen Y.C.
        • Chang C.P.
        • Hsiao C.T.
        • Weng H.H.
        Effectiveness of Sodium Bicarbonate Administration on Mortality in Cardiac Arrest Patients: A Systematic Review and Meta-analysis.
        J Emerg Med. 2020; 59: 856-864
        • Van Walraven C.
        • Stiell I.G.
        • Wells G.A.
        • Hebert P.C.
        • Vandemheen K.
        Do advanced cardiac life support drugs increase resuscitation rates from in-hospital cardiac arrest?.
        Ann Emerg Med. 1998; 32: 544-553
        • Suljaga-Pechtel K.
        • Goldberg E.
        • Strickon P.
        • Berger M.
        • Skovron M.L.
        Cardiopulmonary resuscitation in a hospitalized population: Prospective study of factors associated with outcome.
        Resuscitation. 1984; 12: 77-95
        • Ahn S.
        • Kim Y.J.
        • Sohn C.H.
        • et al.
        Sodium bicarbonate on severe metabolic acidosis during prolonged cardiopulmonary resuscitation: A double-blind, randomized, placebo-controlled pilot study.
        J Thorac Dis. 2018; 10: 2295-2302
        • Ghadimi K.
        • Gutsche J.
        • Ramakrishna H.
        • et al.
        Sodium bicarbonate use and the risk of hypernatremia in thoracic aortic surgical patients with metabolic acidosis following deep hypothermic circulatory arrest.
        Ann Card Anaesth. 2016; 19: 454-462
        • Máttar J.A.
        • Weil M.H.
        • Shubin H.
        • Stein L.
        Cardiac arrest in the critically III. II. Hyperosmolal states following cardiac arrest.
        Am J Med. 1974; 56: 162-168
        • Douglas M.E.
        Alteration of Oxygen Tension and Oxyhemoglobin Saturation.
        Arch Surg. 1979; 114: 326
        • Mukesh T.
        • Prabhat S.
        • Soumya N.
        • Uttam S.
        The Response of the Vascular Beds to Sodium Bicarbonate in Patients During Normothermic Bypass.
        J Cardiothorac Vasc Anesth. 2008; 22: 199-203
        • Kimmoun A.
        • Novy E.
        • Auchet T.
        • Ducrocq N.
        • Levy B.
        Hemodynamic consequences of severe lactic acidosis in shock states: From bench to bedside.
        Crit Care. 2015; 19: 1-13
        • Vanden Hoek T.L.
        • Morrison L.J.
        • Shuster M.
        • et al.
        Part 12: Cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
        Circulation. 2010; 122: S829-S861
      1. Neumar R, Shuster M, Callaway C, et al. 2015 AHA Guidelines update for CPR. 2015. Accessed 8 August 2022, at 2015/Guidelines-RCP-AHA-2015-Full.pdf

        • Miller W.
        • Graham M.G.
        Life-Threatening Electrolyte Abnormalities.
        Circulation. 2000; 102: 217-222
        • Adult Advanced Cardiac Life Support in Guidelines in Cardiopulmonary Resuscitation and Emergency Cardiac Care
        JAMA. 1992; 268: 2199-2241
        • Kawano T.
        • Grunau B.
        • Scheuermeyer F.X.
        • et al.
        Prehospital sodium bicarbonate use could worsen long term survival with favorable neurological recovery among patients with out-of-hospital cardiac arrest.
        Resuscitation. 2017; 119: 63-69
      2. Dawson DE. Home – NEMSIS. Prehospital Emergency Care. Accessed 26 January 2022, at

        • Reynolds J.C.
        • Grunau B.E.
        • Rittenberger J.C.
        • Sawyer K.N.
        • Kurz M.C.
        • Callaway C.W.
        Association between Duration of Resuscitation and Favorable Outcome after Out-of-Hospital Cardiac Arrest: Implications for Prolonging or Terminating Resuscitation.
        Circulation. 2016; 134: 2084-2094
        • Nakahara S.
        • Tomio J.
        • Takahashi H.
        • et al.
        Evaluation of pre-hospital administration of adrenaline (epinephrine) by emergency medical services for patients with out of hospital cardiac arrest in Japan: Controlled propensity matched retrospective cohort study.
        BMJ (Online). 2013; 347: 1-10
        • Leuven E.
        • Sianesi B.
        PSMATCH2: Stata module to perform full Mahalanobis and propensity score matching, common support graphing, and covariate imbalance testing.
        Boston College Department of Economics, 2003
        • Guo S.
        • Fraser M.
        Propensity score matching and related models.
        in: Propensity score analysis: statistical methods and applications. SAGE, 2010: 127-210
        • Nguyen T.L.
        • Collins G.S.
        • Spence J.
        • et al.
        Double-adjustment in propensity score matching analysis: choosing a threshold for considering residual imbalance.
        BMC Med Res Method. 2017; 17: 1-8
      3. Hade EM, Lu B. Bias associated with using the estimated propensity score as a regression covariate; 2013.

        • Delooz H.
        • Resuscitation.
        Are Inter-Center Differences in EMS-Management and Sodium-bicarbonate administration important for the outcome of CPR?.
        Resuscitation. 1989; 17: S161-S172
        • Dybvik T.
        • Strand T.
        • Steen P.A.
        Buffer therapy during out-of-hospital resuscitation.
        Resuscitation. 1995; 29: 89-95
        • Granfeldt A.
        • Wissenberg M.
        • Hansen S.M.
        • et al.
        Clinical predictors of shockable versus non-shockable rhythms in patients with out-of-hospital cardiac arrest.
        Resuscitation. 2016; 108: 40-47
        • Nadkarni V.M.
        • Larkin G.L.
        • Peberdy M.A.
        • et al.
        First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults.
        J Am Med Assoc. 2006; 295: 50-57
        • Rea T.D.
        • Eisenberg M.S.
        • Becker L.J.
        • Murray J.A.
        • Hearne T.
        Temporal trends in sudden cardiac arrest: A 25-year emergency medical services perspective.
        Circulation. 2003; 107: 2780-2785
        • Hara M.
        • Hayashi K.
        • Hikoso S.
        • Sakata Y.
        • Kitamura T.
        Different impacts of time from collapse to first cardiopulmonary resuscitation on outcomes after witnessed out-of-hospital cardiac arrest in adults.
        Circ Cardiovasc Qual Outcomes. 2015; 8: 277-284
        • Chan P.S.
        • Girotra S.
        • Tang Y.
        • Al-Araji R.
        • Nallamothu B.K.
        • McNally B.
        Outcomes for Out-of-Hospital Cardiac Arrest in the United States During the Coronavirus Disease 2019 Pandemic.
        JAMA Cardiol. 2021; 6: 296-303
        • Yan S.
        • Gan Y.
        • Jiang N.
        • et al.
        The global survival rate among adult out-of-hospital cardiac arrest patients who received cardiopulmonary resuscitation: A systematic review and meta-analysis.
        Critical Care. 2020; 24: 1-13