Sodium bicarbonate is an alkalinizing agent.100
Sodium bicarbonate is used parenterally as an alkalinizing agent in the treatment of metabolic acidosis, which may occur in severe renal disease, uncontrolled diabetes, circulatory insufficiency due to shock or severe dehydration, extracorporeal circulation of blood, cardiac arrest, and severe primary lactic acidosis.100 Sodium bicarbonate is also used parenterally for the treatment of certain drug intoxications, including barbiturates, salicylate or methyl alcohol poisoning, and in the treatment of hemolytic reactions requiring alkalinization of the urine to diminish the nephrotoxic effects of blood pigments.100 In addition, sodium bicarbonate is used parenterally in the treatment of severe diarrhea accompanied by substantial GI bicarbonate loss.100
Sodium bicarbonate is available in various over-the-counter (OTC) oral preparations500, 501, 502 including a preparation of sodium bicarbonate in fixed combination with aspirin and citric acid;503 these preparations are used for the treatment of heartburn or dyspepsia.500, 501, 502, 503 Sodium bicarbonate is also available in fixed combination with omeprazole for oral use; see the prescribing information for specific indications and other information regarding combination products.504, 505, 506
IV sodium bicarbonate is used in the treatment of metabolic acidosis associated with many conditions including severe renal disease, uncontrolled diabetes, circulatory insufficiency due to shock or severe dehydration, extracorporeal circulation of blood, cardiac arrest, severe primary lactic acidosis, as well as severe diarrhea with bicarbonate loss.100
The management of metabolic acidosis should, whenever feasible, be superimposed on interventions aimed at controlling the underlying cause, for example, the administration of insulin in cases of uncomplicated diabetes or the restoration of intravascular volume in patients experiencing shock.100 However, given that a significant period may be required for these primary therapeutic effects to manifest, the use of bicarbonate therapy is indicated to minimize the risks associated with the acidotic state.100
Intensive bicarbonate therapy is required in cases where a prompt elevation in plasma total CO2 content is essential, such as during cardiac arrest, circulatory insufficiency resulting from shock or severe dehydration, as well as in severe primary lactic acidosis or severe diabetic acidosis.100
Sodium bicarbonate has also been used orally† in the treatment of mild to moderately severe acidosis, especially in conditions (e.g., chronic kidney disease [CKD]) requiring prolonged therapy with an alkalinizing agent.800, 801, 804, 805, 1004
Data from randomized controlled trials (RCTs) have shown sodium bicarbonate to be effective in the treatment of metabolic acidosis in patients with CKD.800, 801 A meta-analysis of 14 RCTs comprising 2037 patients with CKD and metabolic acidosis found that oral sodium bicarbonate supplementation was more effective in improving estimated glomerular filtration rate (eGFR) compared to placebo, standard care (i.e., routine biochemical laboratory measurements with/without diet intervention), or rescue therapy.800 Another meta-analysis of 20 RCTs and 2 non-randomized clinical trials involving 2932 patients demonstrated the efficacy of oral sodium bicarbonate in treating CKD-induced metabolic acidosis by correcting sodium bicarbonate levels; however, a substantial improvement in eGFR was not observed.801
A systematic review of 44 studies assessed the efficacy of IV sodium bicarbonate administration in the emergent treatment of severe acidemia in adults and pediatric patients with diabetic ketoacidosis (DKA).803 Two included RCTs showed a temporary improvement in metabolic acidosis following bicarbonate administration within the first 2 hours.803 However, there was no evidence to support enhanced glycemic control or overall clinical benefit.803 Retrospective data indicated an increased risk of cerebral edema and extended hospital stays in pediatric patients treated with bicarbonate.803
A meta-analysis of 5 studies enrolling 783 patients did not find a substantial difference in mortality when comparing sodium bicarbonate to no sodium bicarbonate infusion among critically ill patients with high anion gap metabolic acidosis predominantly driven by lactic acidosis.802 However, evidence showed possible mortality and renal benefits in a subgroup of patients with acute kidney injury (AKI).802 A notable RCT included in this meta-analysis is the open-label, multicenter BICAR-ICU study, in which 389 patients with severe metabolic acidemia (pH ≤7.20) were randomized to receive IV 4.2% sodium bicarbonate or no sodium bicarbonate (control), with the aim of achieving an arterial pH >7.3.1003 Sepsis was present in 61% of patients at randomization.1003 The study found no between-group difference in the primary outcome of a composite of 28-day mortality and organ failure at day 7 after admission to the intensive care unit.1003 However, hypernatremia, hypocalcemia, and metabolic alkalosis were observed more frequently with bicarbonate therapy compared to control.1003 In the subgroup of patients with AKI with AKI Network (AKIN) scores of 2 or 3 at randomization (47%), lower mortality was seen with bicarbonate therapy compared to control.1003 No differential effect was observed between patients with or without sepsis.1002, 1003
Findings of the BICAR-ICU study align with the results of another study, which assessed the effectiveness of sodium bicarbonate infusion in patients with sepsis and metabolic acidosis.1001 A total of 1718 patients were enrolled: 500 patients in the IV sodium bicarbonate infusion group and 1218 in the non-sodium bicarbonate group.1001 Sodium bicarbonate therapy was not associated with improved outcome in septic patients with metabolic acidosis; however, an improvement in survival was observed in patients with stage 2 or 3 AKI and severe acidosis.1001
In the open-label, multicenter, BICARICU-2 trial, 640 patients with severe metabolic acidosis and moderate to severe AKI were randomly assigned to either IV sodium bicarbonate infusion or no sodium bicarbonate to target an arterial pH ≥7.3.607 The primary outcome was day 90 all-cause mortality.607 Results revealed no significant effect on mortality with sodium bicarbonate therapy; day 90 all-cause mortality was 62.1% in the sodium bicarbonate group and 61.7% in the control group.607
Normal Anion Gap Metabolic Acidosis
Currently, there are no high-quality studies available on the use of sodium bicarbonate therapy in cases of critical non-anion gap metabolic acidosis (NAGMA).201, 202 Nevertheless, a strong physiological rationale supports the replacement of lost bicarbonate, which supports the use of sodium bicarbonate in this setting and may explain the absence of RCTs.201, 202
According to the 2024 Kidney Disease Improving Global Outcomes (KDIGO) guidelines, individuals with CKD should consider pharmacological treatment with or without dietary intervention to prevent development of metabolic acidosis with potential clinical implications (serum bicarbonate ≤18 mmol/L in adults).804
The American Diabetes Association does not recommend the routine use of bicarbonate in the treatment of DKA.300 In most cases, IV fluids and insulin are sufficient to correct the metabolic acidosis.300 Multiple observational and randomized studies have shown that bicarbonate therapy does not improve heart or brain outcomes, nor does it accelerate the resolution of high blood sugar or ketoacidosis.300 Furthermore, bicarbonate use may cause harmful effects, including a higher risk of low potassium levels, reduced oxygen delivery to tissues, brain swelling, and paradoxical worsening of acidosis in the central nervous system.300 However, in cases of severe acidosis (pH below 7.0), bicarbonate may be considered due to the potential for serious vascular complications.300
Despite controversial evidence, guidance from experts on the management of sepsis and septic shock in adults in the emergency department suggests that sodium bicarbonate is a reasonable treatment for septic patients with severe metabolic or lactic acidosis (bicarbonate levels <5 mEq/L and/or pH <7.1) or with stage 2 or 3 AKI.1000 In such patients, sodium bicarbonate may be an appropriate initial therapy to raise bicarbonate levels and pH while other, more established therapies begin to be effective.1000
The 2021 Surviving Sepsis Campaign guidelines suggest against the use of sodium bicarbonate therapy to improve hemodynamics or to reduce vasopressor requirements in adults with septic shock and hypoperfusion-induced lactic acidemia.1002 The guidelines suggest using sodium bicarbonate therapy in adults with septic shock, severe metabolic acidemia (pH ≤7.2), and AKI (AKIN score 2 or 3).1002
Normal Anion Gap Metabolic Acidosis
NAGMA occurs due to the loss of sodium bicarbonate through the GI tract or the kidneys.201, 202 Severe diarrhea is a common cause of GI bicarbonate loss.201, 202 Guidelines by French experts recommend sodium bicarbonate for GI or renal bicarbonate loss in patients with poor clinical tolerance.1005
Urinary Alkalinization/Drug Intoxication
Intravenous sodium bicarbonate is used for the treatment of certain drug intoxications, including barbiturates (where dissociation of the barbiturate-protein complex is desired) or salicylate or methyl alcohol poisoning, to enhance urinary excretion of these chemicals through urinary alkalinization.100, 903
Most of the evidence on the use of sodium bicarbonate for urinary alkalinization in drug toxicity (e.g., sodium channel blocker poisoning, salicylate intoxication, ingestion of methanol or ethylene glycol) originates from animal research, case reports, case series, and/or expert consensus recommendations.900, 902, 903 Randomized controlled trials assessing the impact of sodium bicarbonate are precluded, likely because of ethical reasons.902
A position paper by the American Academy of Clinical Toxicology (AACT) and the European Association of Poison Centers and Clinical Toxicologists (EAPCCT) defines urine alkalinization as the treatment regimen that increases poison elimination by the administration of IV sodium bicarbonate to produce urine with a pH ≥7.5.903 Data show that urine alkalinization increases the elimination of chlorpropamide, 2,4-dichlorophenoxyacetic acid, diflunisal, fluoride, mecoprop, methotrexate, phenobarbital, and salicylate.903 Based on evidence from human volunteer and clinical studies, urine alkalinization is the first-line treatment approach for patients with moderately severe salicylate poisoning who do not fulfill the criteria for hemodialysis.903 In cases of phenobarbital poisoning, urine alkalinization is not first line as multiple-dose activated charcoal is superior.903 Urine alkalinization and high urine flow of approximately 600 mL/hr should be considered in the management of patients with severe poisoning due to 2,4-dichlorophenoxyacetic acid or mecoprop.903
A guidance document from the American College of Medical Toxicology on salicylate toxicity recommends urinary alkalinization with IV sodium bicarbonate administered as a crystalloid preparation to achieve a pH of 7.5-8.0 to increase excretion of salicylates; IV sodium bicarbonate should be considered for significant salicylate toxicity in patients with intact renal function, alone or in combination with hemodialysis.904
AACT guidelines on the treatment of methanol poisoning recommend that for patients presenting with ophthalmologic abnormalities or significant acidosis, IV sodium bicarbonate should be used to correct the acidosis.900 A pH <7.3 should be treated with IV sodium bicarbonate solution to achieve the normal pH range (7.35-7.45).900 High doses may be necessary to achieve metabolic correction, especially if alcohol dehydrogenase inhibition has not yet occurred and formic acid (methanol metabolite) continues to be produced.900 The addition of bicarbonate to the dialysate during hemodialysis can assist in restoring serum bicarbonate levels; however, the management of acidosis should not be delayed in anticipation of dialysis.900
AACT guidelines on the treatment of ethylene glycol poisoning similarly state that systemic acidosis with a pH <7.3 may be managed with IV sodium bicarbonate to raise the pH to within the normal physiological range (7.35-7.45).901 Large amounts of sodium bicarbonate may be needed in the first several hours in order to correct the metabolic acidosis.901 Additionally, incorporating bicarbonate into the dialysate during hemodialysis can aid in restoring serum bicarbonate levels.901
Advanced Cardiovascular Life Support
Sodium bicarbonate has been used in the management of cardiac arrest.100, 600, 601, 602, 603, 604, 605 However, routine administration of the drug is not recommended by current guidelines.600, 601, 602
Some meta-analyses have evaluated the effect of sodium bicarbonate administration in cardiac arrest and found no benefits on survival.603, 604, 605 A meta-analysis of 6 studies enrolling 21,402 patients with out-of-hospital cardiac arrest found that the administration of sodium bicarbonate during cardiopulmonary resuscitation did not improve either short- or long-term survival compared to the control group; in fact, the long-term survival rate with sodium bicarbonate was lower than that of the control.603 Another meta-analysis of 7 observational studies involving 4877 pediatric patients with in-hospital cardiac arrest showed that administration of sodium bicarbonate during cardiac resuscitation was associated with a substantially decreased survival rate to hospital discharge.604 Similarly, a meta-analysis of 6 observational studies in 18,406 adults with cardiac arrest found no improvement in return of spontaneous circulation or survival-to-discharge rates with sodium bicarbonate treatment in cardiac resuscitation.605
The AHA guidelines for CPR and emergency cardiovascular care state that IV sodium bicarbonate is not recommended for routine use during cardiac arrest in adults.600, 601 There is no new evidence to indicate that routine administration of sodium bicarbonate improves outcomes in cases of undifferentiated cardiac arrest.600, 601 Additionally, evidence suggests that the drug may reduce survival rates and worsen neurological recovery.600, 601 Sodium bicarbonate administered IV is one of the recommended therapies in the management of cardiac arrest with hyperkalemia†, in addition to advanced cardiac life support.600 Additionally, administration of sodium bicarbonate for cardiac arrest or life-threatening cardiac conduction delays (i.e., QRS prolongation >120 ms) due to sodium channel blocker (including tricyclic antidepressant) overdose† can be beneficial.600 The standard therapy for hypotension or cardiotoxicity resulting from sodium channel blocker poisoning includes sodium boluses and serum alkalinization, usually achieved by administering sodium bicarbonate boluses.600 In addition, some experts state that sodium bicarbonate may be considered in the treatment of ventricular arrhythmias associated with cocaine toxicity† in addition to standard treatments.402, 403, 404
The AHA guidelines also do not recommend the routine administration of sodium bicarbonate in pediatric cardiac arrest in the absence of hyperkalemia and sodium channel blocker toxicity, including from tricyclic antidepressants.602 Studies indicate that sodium bicarbonate administration was associated with worse survival outcomes for both in-hospital and out-of-hospital cardiac arrest in this situation.602
Sodium bicarbonate is used in the prevention of contrast-induced nephropathy†.700, 701, 702, 703, 704, 705, 706 In patients at increased risk of contrast-induced AKI, KDIGO recommends IV volume expansion with either isotonic sodium chloride or sodium bicarbonate solutions rather than no IV volume expansion.706
Sodium bicarbonate is used in the management of hyperkalemia†.600, 606 Sodium bicarbonate stimulates the Na+/K+ pump and helps correct underlying metabolic acidemia, which may lead to a decrease in serum potassium levels.606 However, evidence regarding its effectiveness is mixed.403 A guideline on the management of hyperkalemia in the emergency department by KDIGO recommends the use of sodium bicarbonate only in patients with metabolic acidemia who can tolerate the associated sodium load.606 Limited data exist to guide the choice between hypertonic and isotonic bicarbonate solutions; therefore, the decision should be based on the clinical situation, considering factors including the patient's sodium levels and fluid resuscitation needs.606
Sodium bicarbonate is available in various OTC oral preparations; these preparations are used as antacid therapy for heartburn or dyspepsia.500, 501, 502 Sodium bicarbonate is also available OTC in fixed combination with aspirin and citric acid as oral tablets for use as an antacid.503
Sodium bicarbonate is a sterile, nonpyrogenic, hypertonic solution of sodium bicarbonate (NaHCO3) in water for injection.100 Sodium bicarbonate is administered by IV infusion.100 Sodium bicarbonate may be administered by rapid IV injection when initial immediate administration of the drug is considered necessary (e.g., during cardiac arrest).100
Sodium bicarbonate solution is offered in concentrations of 4.2%, 7.5%, and 8.4%; the solutions are available as single-dose vials and/or syringes in various volumes.100, 101, 102, 103, 104, 105
Sodium bicarbonate contains no bacteriostat, antimicrobial agent, or added buffer; it is intended only for use as a single-use injection.100 When smaller doses are required, the unused portion should be discarded.100
Extravasation of hypertonic sodium bicarbonate injections must be avoided.100
In neonates and children younger than 2 years of age, hypertonic sodium bicarbonate injections generally should be administered by slow IV infusion of a 4.2% solution up to 8 mEq/kg daily.100
Sodium bicarbonate injection should be stored at 20-25°C; freezing should be avoided.100, 101, 102, 103, 104, 105 Excessive heat should be avoided.104
Standardized concentrations for sodium bicarbonate have been established through Standardize 4 Safety (S4S), a national patient safety initiative to reduce medication errors, especially during transitions of care .249Multidisciplinary expert panels were convened to determine recommended standard concentrations .249Because recommendations from the S4S panels may differ from the manufacturer's prescribing information, caution is advised when using concentrations that differ from labeling, particularly when using rate information from the label. 249 For additional information on S4S (including updates that may be available), see [Web].249
Patient Population | Concentration Standards | Dosing Units |
|---|---|---|
Pediatric patients (<50 kg) | 0.5 mEq/mL 1 mEq/mL | mEq/kg/hour |
Sodium bicarbonate is available in various over-the-counter (OTC) oral preparations500, 501, 502 including a preparation of sodium bicarbonate in fixed combination with aspirin and citric acid.503 These preparations are used for the treatment of heartburn or dyspepsia.500, 501, 502, 503
Sodium bicarbonate is available in fixed combination with omeprazole for oral use; see the prescribing information for specific information regarding combination products.504, 505, 506
Sodium bicarbonate has been administered by intraosseous (IO) injection† in the setting of pediatric advanced life support; onset of action and systemic concentrations are comparable to those achieved with venous administration.403 However, acid-base balance analysis may be inaccurate after administration of sodium bicarbonate via the IO cannula.403
Sodium bicarbonate 42 mg is equal to 0.5 mEq each of sodium (Na+) and bicarbonate (HCO3 -).100, 101, 102 Sodium bicarbonate 75 mg is equal to 0.892 mEq each of Na+ and HCO3 -.103 Sodium bicarbonate 84 mg is equal to 1 mEq each of Na+ and HCO3 -.102, 103, 104, 105
Dosage of sodium bicarbonate injection is determined by severity of the acidosis, appropriate laboratory determinations, and the patient's age, weight, and clinical condition.100 Frequent laboratory determinations and clinical evaluation of the patient are essential during therapy with sodium bicarbonate, especially during prolonged therapy, to monitor changes in fluid and electrolyte and acid-base balance.100
Generally, full correction of bicarbonate deficit should not be attempted during the first 24 hours of sodium bicarbonate therapy, since this may result in precipitation of metabolic alkalosis because of delayed physiologic compensatory mechanisms.100 Due to this delay, reaching a total CO2 content of approximately 20 mEq/liter by the end of the first day of treatment is typically linked to a normal blood pH.100 Further correction of the acidosis to fully normal levels usually happens if the kidney function is normal and if and when the underlying cause of the acidosis can be controlled.100 If total CO2 levels are normalized or brought above normal within the first day, this may likely result in an excessively high (alkaline) blood pH, which can lead to undesired side effects.100
In cases of metabolic acidosis associated with shock, monitor therapy by assessing blood gases, plasma osmolarity, arterial blood lactate, hemodynamic status, and cardiac rhythm.100 Bicarbonate therapy should always be administered gradually and in stages since the degree of response from a specific dose is not precisely predictable.100
To reverse metabolic acidosis in cardiac arrest, a rapid IV dose of 44.6-100 mEq may be administered initially and continued at a rate of 44.6-50 mEq every 5-10 minutes as necessary based on arterial pH and blood gas monitoring.100 Caution is advised in emergencies where very rapid infusion of large quantities of bicarbonate is indicated.100 Bicarbonate solutions are hypertonic and can cause an unwanted increase in plasma sodium levels while treating metabolic acidosis.100 However, during cardiac arrest, the risks of acidosis outweigh the risks of hypernatremia.100
In less urgent forms of metabolic acidosis, a 2-5 mEq/kg dose of sodium bicarbonate may be administered (added to other IV fluids) as a 4- to 8-hour IV infusion, depending on severity of acidosis (based on total CO2 content, blood pH, and clinical condition of the patient).100 An initial infusion of 2-5 mEq/kg of body weight over 4-8 hours will produce a measurable improvement in the abnormal acid-base status of the blood.100 Subsequent doses should be determined by the response of the patient and appropriate laboratory determinations.100 Sodium bicarbonate therapy should be planned in a stepwise manner, since the degree of response following a given dose is not always predictable.100 Generally, the dose and frequency of administration should be reduced after severe symptoms have improved.100
For the treatment of metabolic acidosis in diabetic ketoacidosis, experts recommend that, if indicated, 100 mmol of sodium bicarbonate (8.4% solution) in 400 mL of sterile water (an isotonic solution) may be administered every 2 hours to achieve a pH >7.0.300
Urinary Alkalinization/Drug Intoxication
To achieve alkalinization in salicylate poisoning in adults, some experts recommend the administration of sodium bicarbonate 225 mmol (225 mL of an 8.4% solution) IV over 1 hour.903 If there is preexisting acidemia, the period of administration of the loading dose of sodium bicarbonate may be shortened and/or the dosage increased.903 Additional boluses of IV sodium bicarbonate may be given to maintain urine pH in the range of 7.5-8.5.903 Urine alkalinization should be discontinued when plasma salicylate levels fall below 350 mg/L in adults.903
Advanced Cardiovascular Life Support
Sodium bicarbonate is not recommended for routine use in advanced cardiovascular life support (ACLS) during cardiac arrest; however, if the drug is used in certain resuscitation situations (e.g., preexisting metabolic acidosis, hyperkalemia, tricyclic antidepressant overdosage), an IV dose of 1 mEq/kg is usually given initially in adults.401 Whenever possible, dosage of sodium bicarbonate should be guided by the bicarbonate concentration or by the calculated base deficit obtained from blood gas analysis or laboratory measurement.401 Complete correction of the base deficit is not recommended to minimize the risk of alkalosis.401
For the management of cardiac arrest due to hyperkalemia† in adults, 50 mEq of sodium bicarbonate has been administered IV over 5 minutes as adjunctive therapy to other standard ACLS measures.196
For the treatment of cardiac arrest or life-threatening cardiac conduction delays (i.e., QRS prolongation >120 ms) due to sodium channel blocker or tricyclic antidepressant overdose†, an initial dose of sodium bicarbonate 1-2 mEq/kg (1-2 mL/kg of 1 mEq/mL [8.4%]) may be administered and repeated as needed to achieve clinical stability while avoiding extreme hypernatremia or alkalemia.600
In neonates and children younger than 2 years of age, hypertonic sodium bicarbonate injections generally should be administered by slow IV infusion of a 4.2% solution up to 8 mEq/kg daily.100
In less urgent forms of metabolic acidosis, a 2-5 mEq/kg dose of sodium bicarbonate may be administered (added to other IV fluids) to older children as a 4- to 8-hour IV infusion, depending on severity of acidosis (based on total CO2 content, blood pH, and clinical condition of the patient).100 An initial infusion of 2-5 mEq/kg of body weight over 4-8 hours will produce a measurable improvement in the abnormal acid-base status of the blood.100 Subsequent doses should be determined by the response of the patient and appropriate laboratory determinations.100 Sodium bicarbonate therapy should be planned in a stepwise manner, since the degree of response following a given dose is not always predictable.100 Generally, the dose and frequency of administration should be reduced after severe symptoms have improved.100
Alternatively, for the treatment of metabolic acidosis, some experts recommend a pediatric dosage of 0.5-1 mEq/kg, administered by IV or IO† injection over 5-15 minutes (maximum single dose: 50 mEq).405 Only the 0.5 mEq/mL (4.2%) concentration should be used for newborn infants.405
Urinary Alkalinization/Drug Intoxication
To achieve alkalinization in salicylate poisoning in children, some experts recommend the administration of sodium bicarbonate 25-50 mmol (25 mL of an 8.4% solution) IV over 1 hour.903 If there is preexisting acidemia, the period of administration of the loading dose of sodium bicarbonate may be shortened and/or the dose increased.903 Additional boluses of IV sodium bicarbonate may be given to maintain urine pH in the range of 7.5-8.5.903 Urine alkalinization should be discontinued when plasma salicylate levels fall below 250 mg/L in children.903
For the treatment of tricyclic antidepressant or other sodium channel blocker overdose†, some experts recommend the administration of sodium bicarbonate boluses of 1-2 mEq/kg until the arterial pH is >7.45, followed by continuous IV infusion of 150 mEq NaHCO3 per liter of D5W in order to maintain alkalosis; in cases of severe intoxication, the pH should be increased to 7.5-7.55.404 Similarly, other pediatric experts recommend the administration of a 1-2 mEq/kg bolus of sodium bicarbonate, repeated in 5 minutes if there is no response, followed by infusion of 150 mEq NaHCO3/L solution.405 A goal pH of 7.5-7.55 is recommended in tricyclic antidepressant poisoning with hypotension, widened QRS interval >100 ms, or ventricular arrhythmia.405
For the treatment of hyperkalemia†, some experts recommend a pediatric dosage of 1 mEq/kg, administered slowly by IV or IO† injection, over 10-15 minutes (maximum single dose: 50 mEq).405 Only the 0.5 mEq/mL (4.2%) concentration should be used for newborn infants.405
Advanced Cardiovascular Life Support/Pediatric Resuscitation
If sodium bicarbonate is used for pediatric resuscitation, the guidelines for pediatric advanced life support recommend a pediatric dose of 1 mEq/kg, administered slowly by IV or IO† injection, after adequate ventilation.403
If sodium bicarbonate is used for metabolic acidosis or hyperkalemia associated with cardiac arrest†, some experts similarly recommend a dosage of 1 mEq/kg bolus, administered slowly by IV or IO† injection (maximum single dose: 50 mEq).405 The rate of administration should not exceed 10 mEq/minute.405 The 4.2% concentration is recommended for infants and children <2 years of age.405
For the treatment of ventricular arrhythmias associated with cocaine toxicity† in pediatric patients, 1-2 mEq/kg of IV sodium bicarbonate has been administered in addition to standard treatment.402, 403, 404
The manufacturer makes no specific dosage recommendations for patients with hepatic impairment.100
The manufacturer makes no specific dosage recommendations for patients with renal impairment.100
The manufacturer makes no specific dosage recommendations for geriatric patients.100 In general, dosage selection for geriatric patients should be cautious, usually starting at the low end of the dosing range, reflecting the higher incidence of decreased hepatic, renal, or cardiac function and of concomitant disease or other drug therapy.100
Inadvertent extravasation of hypertonic solutions of sodium bicarbonate has reportedly caused chemical cellulitis because of their alkalinity, subsequently resulting in tissue necrosis, ulceration, and/or sloughing at the site of injection.100 It is recommended that extravasation be treated by elevating the affected area, applying warm compresses to the site, and locally injecting lidocaine or hyaluronidase.100
Avoid extravascular infiltration.100
Sodium and water retention and edema may occur during sodium bicarbonate therapy, especially when the drug is given in large doses or to patients with renal insufficiency, congestive heart failure, or those predisposed to sodium retention and edema.100
IV administration of sodium bicarbonate may cause fluid and/or solute overload resulting in dilution of serum electrolytes, overhydration, congestive conditions, or pulmonary edema.100
Sodium bicarbonate should be used with extreme caution in patients with congestive heart failure or other edematous or sodium-retaining conditions; in patients with renal insufficiency, especially those with severe insufficiency such as oliguria or anuria; and in patients receiving corticosteroids or corticotropin.100
Generally, the goal of alkalinizing therapy is to correct the acid-base disturbance while avoiding overdosage and resultant metabolic alkalosis.100 Overly aggressive therapy with sodium bicarbonate may cause metabolic alkalosis.100 Metabolic alkalosis may be associated with hyperirritability, muscle twitching, and tetany.100
Potassium depletion may predispose to metabolic alkalosis and coexistent hypocalcemia may result in tetany and carpopedal spasm as the plasma pH increases.100 To minimize the risks of preexisting hypokalemia and/or hypocalcemia, these electrolyte disturbances should be corrected prior to initiation of, or concomitantly with, sodium bicarbonate therapy.100
To minimize the possibility of overdosage and alkalosis, repeated fractional doses and periodic monitoring by appropriate laboratory tests are recommended.100
If alkalosis occurs, sodium bicarbonate should be stopped, and the patient should be managed according to the degree of alkalosis present.100 IV sodium chloride 0.9% may be administered; potassium chloride may also be indicated if hypokalemia is present.100 Severe bicarbonate-induced alkalosis may be accompanied by hyperirritability or tetany, which may be controlled with calcium gluconate; an acidifying agent (e.g., ammonium chloride) may also be indicated in severe alkalosis.100
Animal reproduction studies have not been performed with sodium bicarbonate.100 It is also not known whether sodium bicarbonate can cause fetal harm when administered to pregnant women.100 Sodium bicarbonate should be used during pregnancy only when clearly needed.100
The manufacturer provides no specific information for use of sodium bicarbonate during breast-feeding.100
Rapid injection (10 mL/minute) of hypertonic sodium bicarbonate solutions in neonates and children younger than 2 years of age may produce hypernatremia, decreased CSF pressure, and possible intracranial hemorrhage.100 It is recommended that the rate of IV administration in these children not exceed 8 mEq/kg daily and that slow IV administration of a 4.2% solution may be preferred.100 In emergencies such as cardiac arrest, the risk of rapid infusion of the drug in these children must be weighed against the potential for death from acidosis.100
Clinical studies of sodium bicarbonate did not include sufficient numbers of patients ≥65 years of age to determine whether they respond differently from younger subjects.100 Other reported clinical experience has not identified differences in responses between geriatric and younger patients.100
In general, dosage selection for geriatric patients should be cautious, usually starting at the low end of the dosing range, reflecting the higher incidence of decreased hepatic, renal, or cardiac function and of concomitant disease or other drug therapy.100
The manufacturer provides no specific information regarding use of sodium bicarbonate in patients with hepatic impairment.100
In patients with renal impairment, administration of solutions containing sodium ions may result in sodium retention.100
Solutions containing sodium ions should be used with extreme caution, if at all, in patients with severe renal insufficiency.100
Adverse effects from IV sodium bicarbonate treatment include manifestations of metabolic alkalosis (muscular twitching, irritability, and tetany); hypernatremia; and chemical cellulitis with tissue necrosis, ulceration or sloughing at the site of infiltration from extravasation.100
Additives may be incompatible with sodium bicarbonate solution.100 Norepinephrine and dobutamine are incompatible with sodium bicarbonate solution.100
Avoid the addition of sodium bicarbonate to parenteral solutions containing calcium, except where compatibility has been previously established.100 Precipitation or haze may result from sodium bicarbonate and calcium admixtures.100 Do not use the injection if precipitates are observed.100
Consult with a pharmacist regarding use of additives.100 When introducing additives, use aseptic technique, mix thoroughly, and do not store.100
Corticosteroids and Corticotropin
Caution must be exercised when administering parenteral fluids containing sodium ions, such as sodium bicarbonate, to patients receiving corticosteroids or corticotropin due to potential for edema.100
Sodium bicarbonate is a systemic alkalizer and electrolyte replenisher.100 IV administration of sodium bicarbonate elevates plasma bicarbonate concentrations, buffers excess hydrogen ions, increases systemic pH, and reverses the clinical manifestations of acidosis.100
In aqueous solution, sodium bicarbonate dissociates into sodium (Na+) and bicarbonate (HCO3 -) ions.100 Sodium, the predominant extracellular cation, plays a critical role in the management of fluid and electrolyte disturbances.100 Bicarbonate is an endogenous constituent of body fluids, with normal plasma concentrations ranging from 24-31 mEq/L.100 Plasma concentrations are maintained by renal mechanisms, through urinary acidification in states of deficit or urinary alkalinization in states of excess.100
Sodium bicarbonate solution has an approximate pH of 8.0 (7.0-8.5).100, 101, 102, 103, 104, 105 Sodium bicarbonate solutions contain equal amounts (mEq/mL) each of sodium and bicarbonate ions.100, 101, 102, 103, 104, 105 The 8.4, 7.5, and 4.2% concentration solutions contain 1 mEq/mL, 0.892 mEq/mL, and 0.5 mEq/mL, respectively, of each ion.100, 101, 102, 103, 104, 105 These solutions are very hyperosmolar— 2000 mOsm/L for the 8.4% concentration and 1786 mOsm/L for the 7.5% concentration.201
The bicarbonate anion is considered chemically labile, as it may combine with hydrogen ions to form carbonic acid (H2CO3), which subsequently converts to its volatile form, carbon dioxide (CO2), which is excreted by the lungs.100 Under physiologic conditions, the extracellular fluid maintains a 1:20 ratio of carbonic acid to bicarbonate.100 In adults with normal renal function, virtually all bicarbonate filtered at the glomerulus is reabsorbed, with urinary excretion typically accounting for <1%.100
Oral administration of sodium bicarbonate leads to systemic absorption of excess bicarbonate, which induces metabolic alkalosis and promotes urinary alkalinization.200 IV administration achieves complete bioavailability.200 The onset of action after an IV push is rapid, with a mean onset of 8-10 minutes.201 Sodium bicarbonate is extensively distributed within the extracellular fluid compartment.200 The elimination half-life of sodium bicarbonate is unknown.200
Additional Information
The American Society of Health-System Pharmacists, Inc. represents that the information provided in the accompanying monograph was formulated with a reasonable standard of care, and in conformity with professional standards in the field. Readers are advised that decisions regarding use of drugs are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and that the information contained in the monograph is provided for informational purposes only. The manufacturer's labeling should be consulted for more detailed information. The American Society of Health-System Pharmacists, Inc. does not endorse or recommend the use of any drug. The information contained in the monograph is not a substitute for medical care.
Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.
Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.
Routes | Dosage Forms | Strengths | Brand Names | Manufacturer |
|---|---|---|---|---|
Parenteral | Injection | 4.2% (0.5 mEq/mL) (2.5 or 5 mEq)* | Sodium Bicarbonate Injection | |
7.5% (0.892 mEq/mL) (44.6 mEq)* | Sodium Bicarbonate Injection | |||
8.4% (1 mEq/mL) (10 or 50 mEq)* | Sodium Bicarbonate Injection |
* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name
Only references cited for selected revisions after 1984 are available electronically.
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