Jon-Emile S. Kenny MD [@heart_lung] “What is REAL?” -Velveteen Rabbit A 42 year old woman with poorly-controlled type II diabetes is admitted with a severe soft tissue infection of her left lower extremity. She is hypotensive with altered sensorium and she is noted to have a rapidly progressing border of deep, crimson erythema and edema upwards along her inner thigh; she had been recently scratched by her cat there. Her serum glucose is over 700 mg/dL and her creatinine has eclipsed 3 times her known baseline. While her urinalysis is without ketones, she has an anion gap of 22 mEq/L with an albumin of 4.4 mg/dL. Her lactate is 8.0 mmol/L with an arterial pH of 7.14. She is noted to have deep respirations with a measured PaCO2 of 22 mmHg and a venous CO2 tension of 38 mmHg drawn from a subclavian central line placed in the ED. The evening critical care fellow opts to administer sodium bicarbonate, but the admitting ICU resident asks her why sodium bicarbonate is indicated in the setting of ‘