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Home , Sodium bicarbonate

Sodium

Brand names Generics, available in concentrations of 0.5 mEq HCO3/mL (4.2%), 0.6 mEq/mL (5%), 0.9 mEq/mL (7.5%), and 1 mEq/mL (8.4%)

Medication error Look-alike, sound-alike drug names potential USP reports that bicarbonate has been confused with and patient harm resulted.(1)

Contraindications Contraindications: Ongoing chloride losses as in vomiting or GI suction; those receiving and warnings diuretics known to cause a hypochloremic ; hypocalcemia.(2)

Infusion-related Sodium bicarbonate should be infused slowly in neonates to decrease possible hyperna- cautions tremia that may decrease cerebrospinal fluid, pressure and result in intracranial hemor- rhage.(2-4) The manufacturer recommends an infusion rate not to exceed 0.33 mEq/kg/hr in infants and children up to 2 years of age to reduce the risk of intracranial hemorrhage.(2) However, in , faster infusion rates may be warranted.(2) Extravasation may cause local ischemia and tissue necrosis.(2) (See Appendix E for man- agement of extravasation of concentrated products.)

Dosage CPR: Sodium bicarbonate should only be used after establishment of airway and adequate ventilation.(5,6) Routine use of sodium bicarbonate does not improve the outcome of cardiac arrest in children; however, there are certain times when its use can be considered.(5,6) The 4.2% solution (0.5 mEq/mL) should be used in newborns and infants up to 2 years of age.(2,5) Cardiac arrest: 1 mEq/kg followed by 0.5 mEq/kg q 10 min during continued arrest(2) Hyperkalemic cardiac arrest: 1 mEq/kg(6) up to 50 mEq/dose in adults(7) -induced ventricular arrhythmia: 1–2 mEq/kg(6) , sodium channel blocker toxicity: Boluses of 1–2 mEq/kg until arterial pH is >7.45; then use continuous infusion (150 mEq/L in D5W solution) to maintain alkalosis (arterial pH 7.45–7.55). In cases of severe intoxication, maintain arterial pH 7.50–7.55.(5,6) Metabolic : Calculate the sodium bicarbonate dose using the following equations(2,8): HCO3 (mEq) = 0.3 × weight (kg) × deficit (mEq/L), or HCO3 (mEq) = 0.5 × weight (kg) × [24 – serum HCO3 (mEq/L)] If laboratory measurements are not available: 2–5 mEq/kg administered over 4–8 hours. Subsequent doses should be individualized based on response and severity of metabolic acidosis.(2,8) Complete correction of the base deficit should occur over >24 hours because the compensatory response to changes in ventilation may be delayed.(2) (DKA): Adjunctive bicarbonate (1–2 mEq/kg over 60 min- utes) may be considered in children with severe DKA and a pH <6.9.(9,10) However, a retrospective study reported no difference in rate of metabolic recovery and complica- tions between patients treated with or without bicarbonate, and hospitalization was prolonged in the bicarbonate group.(11) The administration of bicarbonate has also been associated with development of cerebral edema.(12) Urinary alkalinization (see the Comments section): Poisonings (salicylate) in children(13): 25 mEq infused over 1 hour. Urine pH should be measured every 15–30 minutes and additional doses given until the urine pH is 7.5–8.5, then urine pH should be measured hourly. Potassium concentrations should be measured hourly. The arterial pH should be ≤7.5.  780 Sodium Bicarbonate

Dosage (cont.) Prevention of (14): D5¼NS with 50–100 mEq/L NaHCO3 (no potassium) infused at 3–6 L/m2/day and titrated to a urinary pH of 7–7.5. Serum HCO3 concentration should be kept ≤30 mEq/L. An alternative strategy for urine alkalinization has been reported in 26 patients ages 15–25 years old receiving high-dose methotrexate without hyperhydration. These patients received 500 mEq sodium bicarbonate over 1 hour before the methotrexate dose on day 1, then again on days 2–4 of therapy. Urine pH remained above 7.5 in all patients.(15)

Dosage adjustment Use with caution in patients with renal insufficiency, congestive heart failure, or in those in organ dysfunction with edema and sodium retention.(2)

Maximum dosage 2 mEq/kg/dose,(5) 8 mEq/kg/day in infants,(2,3) 2–5 mEq/kg as intermittent infusions over 4–8 hours.(2) Adolescents and young adults received 500 mEq over 1 hour as part of a hyperalkalinization regimen for high-dose methotrexate.(15)

Additives Each gram of sodium bicarbonate provides 12 mEq sodium.(16) The 5% solution in 500-mL bottles also contains 0.9 mg/mL of edetate disodium.(17)

Suitable diluents D5NS, D5W, D10W, D5LR, R(16)

Maximum Neonates and infants: 4.2% (0.5 mEq/mL)(2) concentration >2 years: 8.4% (1 mEq/mL)(2)

Preparation and Compatibility: Bicarbonate is incompatible with norepinephrine and dobutamine.(17) delivery Adequately flush the IV lines between administration of resuscitation drugs and sodium bicarbonate.(6) Incompatible with containing fluids.(2)

IV push This method of administration is indicated in cardiac arrest.(6) May administer over 5 minutes in adults.(7)

Intermittent infusion 2–5 mEq/kg over 4–8 hours in older children(2)

Continuous infusion May be given continuously. In nonemergent situations, rate should not exceed 0.33 mEq/kg/hr for infants and children up to 2 years of age to decrease risk of intracranial hemorrhage.(2)

Other routes of May be administered IO if unable to establish adequate IV access during cardiac arrest.(6) administration

Comments Urinary alkalinization and forced have been used to prevent acute renal failure due to . However, a retrospective review of 1771 adults with rhabdomyolysis due to trauma who received bicarbonate and forced diuresis found that renal failure was not decreased when compared to a group that did not receive this treatment.(18) Monitoring: Electrolytes, including potassium and calcium, should be monitored.(2) Measurement of arterial pH (blood gas) is indicated during resuscitation. Potassium con- centration and pH are inversely related; therefore, increases in pH result in a decrease in potassium concentration. Blood calcium binding to albumin is enhanced with alkalosis resulting in decreased ionized calcium. Urinary pH should be measured during urinary alkalinization.  781