Sodium bicarbonate: Difference between revisions

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Hyperosmolar solution.
==Administration==
Presentation-50 mmol/50 mL pre-filled syringe,100 mmol/100 mL vial
*Type: 8.4% is common cardiac formulation
**8.4% is 1 mEq/mL
*Dosage Forms: 5% ; 7.5% ; 8.4% ; 4.2% ; 4% ; 325mg ; 150 mEq/1000 mL-D5% ; 150 mEq/1150 mL-D5%
*Routes of Administration: IV
*Common Trade Names: N/A
*Abbreviation: NaHOC3
{{Dosing Variables}}


'''Indications:'''
==Adult Dosing==
-Hyperkalemia
===[[Cardiac Arrest]]===
-decr pain due to LA
{{#var:bicarbmax}} mL (1 amp) IV push for severe acidemia and patient is adequately ventilated
'''Toxicological indications-'''
*Frequency<ref>eMedicine. Sodium Bicarbonate. http://reference.medscape.com/drug/sodium-bicarbonate-antidote-343749</ref>:
Cardiotoxicity secondary to fast sodium channel blockade-TCA,Bupropion,Chloroquine/hydroxychloroquine,Dextropropoxyphene,Propranolol.
**1 mEq/kg IV bolus dose initially (~1-2 amps for average adult)
Prevent redistribution of drug to CNS-Severe salicylate poisoning.
**0.5 mEq/kg/dose q10min
Profound life-threatening metabolic acidosis-Cyanide,Toxic alcohol poisoning,Isoniazid overdose.
**'''OR''' tailor to serial ABGs
Enhance urinary drug elimination-Salicylate,Phenobarbitone intoxication.
Increase urinary solubility-Methotrexate toxicity.Drug-induced rhabdomyolysis


'''Contraindications:'''
===Severe [[Metabolic Acidemia]] (pH<7.1) ===
Acute pulmonary oedema
*IV drip
Hypokalaemia
**150 mEq/1000 mL inD5W
Metabolic or respiratory alkalosis
**May reduce 28 day mortality in patients with severe AKI and decrease need for dialysis (although this study used 4.2% sodium bicarbonate, a product not widely available within the United States)<ref>Jaber, S., Paugam, C., Futier, E., Lefrant, J.-Y., Lasocki, S., Lescot, T., … BICAR-ICU Study Group. (2018). Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomised controlled, phase 3 trial. The Lancet, 392(10141), 31–40.</ref>
Poorly controlled congestive cardiac failure
Renal failure
Severe hypernatraemia.


'''Adverse drug reactions:'''
===Serum alkalinization (toxicology)===
Alkalosis (serum pH >7.6 is detrimental to cardiovascular function)
*Enhance urinary elimination of salicylates, methotrexate and phenobarbital
Hypernatraemia and hyperosmolarity
*Goal: serum pH of 7.5, urinary pH of 8.0
Fluid overload and acute pulmonary oedema
*Check K+ as well
Hypokalaemia
*IV drip
Local tissue inflammation secondary to extravasation
**150 mEq (3 amps) of 8.4% solution in 1000 ml D5W + potassium 20-40 mEq, max. 250 cc/hour


'''Administration:'''
==Pediatric Dosing==
'''Cardiotoxicity secondary to fast sodium channel blockade:'''
===[[Cardiac Arrest]]===
Resuscitation from severe cardiotoxicity (cardiac arrest, ventricular arrhythmias and hypotension)
*{{#var:bicarb}} mL/kg IV push for severe acidemia and patient is adequately ventilated
Give repeated boluses of 2 mmol/kg IV until cardiovascular stability is achieved
*Sodium bicarbonate administration in cardiac arrest has not been shown to improve survival to discharge<ref>Dybvik T, Strand T, Steen PA. Buffer therapy during out-of-hospital cardiopulmonary resuscitation. Resuscitation. 1995 Apr;29(2):89-95. doi: 10.1016/0300-9572(95)00850-s. PMID: 7659873.</ref><ref>Vukmir RB, Katz L; Sodium Bicarbonate Study Group. Sodium bicarbonate improves outcome in prolonged prehospital cardiac arrest. Am J Emerg Med. 2006 Mar;24(2):156-61. doi: 10.1016/j.ajem.2005.08.016. PMID: 16490643.</ref>
'''Maintenance of serum alkalinisation in severe cardiotoxicity:'''
*ACLS guidelines recommend against routine use of sodium bicarbonate in cardiac arrest although there may be benefit in the setting of cardiac arrest caused by [[hyperkalemia]] or [[Tricyclic antidepressant toxicity|tricyclic antidepressant]] overdose
Consider following resuscitation in the presence of ventricular arrhythmias, hypotension, or a markedly wide QRS complex (>140 ms)
Commence an infusion of 100 mmol sodium bicarbonate diluted in 1000 mL normal saline at 250 mL/hour
Hourly ABGs and maintain serum pH 7.50–7.55
Cease following resolution of cardiovascular toxicity as determined by clinical and ECG criteria
'''Prevention of redistribution of salicylate to CNS:'''
Maintain pH above 7.4 at all times
Intubated pt-serum pH may be maintained >7.4 by hyperventilation
Unwell un-intubated patient with salicylate poisoning-Give sodium bicarbonate 2 mmol/kg IV bolus,Then intubate, hyperventilate and recheck ABGs.
Serum alkalinisation is maintained until definitive care with haemodialysis.
'''Urinary alkalinisation:'''
Correct hypokalaemia if present.Give 1–2 mmol/kg sodium bicarbonate IV bolus
Commence infusion of 100 mmol sodium bicarbonate in 1000 mL 5% dextrose at 250 mL/hour
20 mmol of KCl may be added to infusion to maintain normokalaemia
Monitor serum bicarbonate and potassium at least every 4 hours
Regularly dipstick urine and aim for urinary pH >7.5 .Continue until resolving clinical and laboratory evidence of toxicity.


'''Specific considerations:'''
==Special Populations==
'''Pregnancy:''' No restriction on use
*[[Drug Ratings in Pregnancy|Pregnancy Rating]]: C
'''Lactation:''' No restriction on use
*[[Lactation risk categories|Lactation risk]]: Infant risk minimal
'''Paediatric:''' Doses are the same as for adults on mmol/kg basis. Reduced fluid volumes should be used in children.
===Renal Dosing===
*Adult:
*Pediatric:
===Hepatic Dosing===
*Adult:
*Pediatric:
 
==Contraindications==
*Allergy to class/drug
*Relative:
**Ongoing chloride loss (vomiting, gastrointestinal suction, with concurrent diuretics that induce hypochloremia)
**[[DKA]] with pH > 7.1
 
==Adverse Reactions==
===Serious===
*Extravasation: [[cellulitis]], tissue necrosis, ulcer
*[[Metabolic alkalosis]]
*[[Hypernatremia]] <ref>Aufderheide TP, Martin DR, Olson DW, Aprahamian C, Woo JW, Hendley GE, Hargarten KM, Thompson B. Prehospital bicarbonate use in cardiac arrest: a 3-year experience. Am J Emerg Med. 1992 Jan;10(1):4-7. doi: 10.1016/0735-6757(92)90115-e. PMID: 1736913.</ref>
 
===Common===
 
==Pharmacology==
*Onset: 15 minutes (IV)
*Duration: 1-2 hours (IV)
*Half-life:
*Metabolism:
*Excretion:
 
==Mechanism of Action==
*Bicarbonate reacts with H+ ions to form water & carbon dioxide. It acts as a buffer against acidosis by raising blood pH
 
==Comments==
*'''Sodium acetate''' can be used as a substitute for sodium bicarbonate during times of critical shortages<ref>Neavyn MJ,Boyer EW, Bird SB, Babu KM. Sodium Acetate as a Replacement for Sodium Bicarbonate in Medical Toxicology: a Review. J Med Toxicol. 2013;9:250–254.</ref>
**Can be used to treat [[TCA toxicity|TCA]] and [[ASA toxicity]]
**Cannot be given as a rapid bolus - give 1 mEq/kg over 15-20 minutes to avoid hypotension
 
==See Also==
 
==References==
<references/>
[[Category:Pharmacology]]
[[Category:Critical Care]]

Latest revision as of 20:28, 13 September 2023

Administration

  • Type: 8.4% is common cardiac formulation
    • 8.4% is 1 mEq/mL
  • Dosage Forms: 5% ; 7.5% ; 8.4% ; 4.2% ; 4% ; 325mg ; 150 mEq/1000 mL-D5% ; 150 mEq/1150 mL-D5%
  • Routes of Administration: IV
  • Common Trade Names: N/A
  • Abbreviation: NaHOC3



Adult Dosing

Cardiac Arrest

50 mL (1 amp) IV push for severe acidemia and patient is adequately ventilated

  • Frequency[1]:
    • 1 mEq/kg IV bolus dose initially (~1-2 amps for average adult)
    • 0.5 mEq/kg/dose q10min
    • OR tailor to serial ABGs

Severe Metabolic Acidemia (pH<7.1)

  • IV drip
    • 150 mEq/1000 mL inD5W
    • May reduce 28 day mortality in patients with severe AKI and decrease need for dialysis (although this study used 4.2% sodium bicarbonate, a product not widely available within the United States)[2]

Serum alkalinization (toxicology)

  • Enhance urinary elimination of salicylates, methotrexate and phenobarbital
  • Goal: serum pH of 7.5, urinary pH of 8.0
  • Check K+ as well
  • IV drip
    • 150 mEq (3 amps) of 8.4% solution in 1000 ml D5W + potassium 20-40 mEq, max. 250 cc/hour

Pediatric Dosing

Cardiac Arrest

  • 1 mL/kg IV push for severe acidemia and patient is adequately ventilated
  • Sodium bicarbonate administration in cardiac arrest has not been shown to improve survival to discharge[3][4]
  • ACLS guidelines recommend against routine use of sodium bicarbonate in cardiac arrest although there may be benefit in the setting of cardiac arrest caused by hyperkalemia or tricyclic antidepressant overdose

Special Populations

Renal Dosing

  • Adult:
  • Pediatric:

Hepatic Dosing

  • Adult:
  • Pediatric:

Contraindications

  • Allergy to class/drug
  • Relative:
    • Ongoing chloride loss (vomiting, gastrointestinal suction, with concurrent diuretics that induce hypochloremia)
    • DKA with pH > 7.1

Adverse Reactions

Serious

Common

Pharmacology

  • Onset: 15 minutes (IV)
  • Duration: 1-2 hours (IV)
  • Half-life:
  • Metabolism:
  • Excretion:

Mechanism of Action

  • Bicarbonate reacts with H+ ions to form water & carbon dioxide. It acts as a buffer against acidosis by raising blood pH

Comments

  • Sodium acetate can be used as a substitute for sodium bicarbonate during times of critical shortages[6]
    • Can be used to treat TCA and ASA toxicity
    • Cannot be given as a rapid bolus - give 1 mEq/kg over 15-20 minutes to avoid hypotension

See Also

References

  1. ↑ eMedicine. Sodium Bicarbonate. http://reference.medscape.com/drug/sodium-bicarbonate-antidote-343749
  2. ↑ Jaber, S., Paugam, C., Futier, E., Lefrant, J.-Y., Lasocki, S., Lescot, T., … BICAR-ICU Study Group. (2018). Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomised controlled, phase 3 trial. The Lancet, 392(10141), 31–40.
  3. ↑ Dybvik T, Strand T, Steen PA. Buffer therapy during out-of-hospital cardiopulmonary resuscitation. Resuscitation. 1995 Apr;29(2):89-95. doi: 10.1016/0300-9572(95)00850-s. PMID: 7659873.
  4. ↑ Vukmir RB, Katz L; Sodium Bicarbonate Study Group. Sodium bicarbonate improves outcome in prolonged prehospital cardiac arrest. Am J Emerg Med. 2006 Mar;24(2):156-61. doi: 10.1016/j.ajem.2005.08.016. PMID: 16490643.
  5. ↑ Aufderheide TP, Martin DR, Olson DW, Aprahamian C, Woo JW, Hendley GE, Hargarten KM, Thompson B. Prehospital bicarbonate use in cardiac arrest: a 3-year experience. Am J Emerg Med. 1992 Jan;10(1):4-7. doi: 10.1016/0735-6757(92)90115-e. PMID: 1736913.
  6. ↑ Neavyn MJ,Boyer EW, Bird SB, Babu KM. Sodium Acetate as a Replacement for Sodium Bicarbonate in Medical Toxicology: a Review. J Med Toxicol. 2013;9:250–254.
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