The use of acid buffers during cardiopulmonary resuscitation: a time to change again?

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Abstract
Buffer therapy, especially sodium bicarbonate (SB), is still one of the most controversial issues in cardiopulmonary resuscitation. This critical review focuses around four issues: 1) the necessity of buffer therapy, 2) evidence for its beneficial effects, 3) evidence for its detrimental effects, and 4) differences among the various available buffers. The major conclusions of this review are: 1) significant, deleterious metabolic acidosis often exists at the time that drugs (epinephrine) are initiated during cardiopulmonary resuscitation. 2) Although clinical evidence is lacking, buffer therapy is probably beneficial when used in conjunction with effective ventilation and measures to optimize tissue perfusion. 3) No substantial evidence shows a detrimental effect of buffer therapy, specifically sodium bicarbonate; if appropriately used, sodium bicarbonate does not increase serum sodium and osmolarity, does not interfere with oxygen release, does not increase tissue carbon dioxide concentrations, and does not paradoxically worsen intracellular acidosis. 4) Despite theoretic differences, there is not enough factual basis to favor the use of other buffers over sodium bicarbonate. Prospective clinical trials and more laboratory research using relevant experimental models are badly needed to resolve the important controversy over buffer therapy in cardiopulmonary resuscitation.