Uses

Acidosis

Treatment of metabolic acidosis associated with many conditions including severe renal disease (e.g., renal tubular acidosis), uncontrolled diabetes (ketoacidosis), extracorporeal circulation of the blood, cardiac arrest, circulatory insufficiency caused by shock or severe dehydration, ureterosigmoidostomy, lactic acidosis, alcoholic ketoacidosis, use of carbonic anhydrase inhibitors, and ammonium chloride administration.

Generally considered the alkalinizing agent of choice for oral or parenteral therapy.

Diabetic Ketoacidosis

Specific role of sodium bicarbonate therapy in the treatment of diabetic ketoacidosis not established. Administration is generally reserved for the treatment of severe acidosis (e.g., arterial pH less than 7–7.15 or serum bicarbonate concentration of 8 mEq/L or less) because of the potential risks of sodium bicarbonate therapy in the treatment of this disorder.

Cardiopulmonary Resuscitation

The Guidelines on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care state that IV sodium bicarbonate is not recommended for routine use in advanced cardiovascular life support (ACLS). Consider use only after more proven interventions such as defibrillation, cardiac compression, support of ventilation including intubation, and vasopressor therapy have been ineffective or in patients with a clearly defined diagnosis (e.g., patients with preexisting acidosis with or without hyperkalemia; prolonged cardiac arrest or resuscitative efforts; unstable hemodynamic state with documented metabolic acidosis; phenobarbital or tricyclic antidepressant overdosage).

Alkalinization of Urine

Treatment of hemolytic reactions requiring alkalinization of the urine to diminish the nephrotoxic effects of blood pigments; also to increase urinary pH in order to increase the solubility of certain weak acids (e.g., cystine, sulfonamides, uric acid).

Dosage and Administration

General

• Dosage is determined by severity of the acidosis, appropriate laboratory determinations, and the patient’s age, weight, and clinical condition. Frequent laboratory determinations and clinical evaluation of the patient are essential during therapy, especially during prolonged therapy, to monitor changes in fluid and electrolyte and acid-base balance.
• 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.
• Fluid and electrolyte balance of the patient must be carefully monitored during therapy with the drug because of the sodium content of sodium bicarbonate.

Administration

Administer orally, by direct IV injection or infusion.

May be administered by intraosseus injection† in pediatric patients without reliable/immediate IV access undergoing cardiopulmonary resuscitation..

Also administered by subcutaneous injection if diluted to isotonicity (1.5% sodium bicarbonate solution); avoid extravasation of hypertonic sodium bicarbonate injections.

Oral Administration

Administered orally in the treatment of mild to moderately severe acidosis, in conditions (e.g., chronic renal failure) requiring prolonged therapy with an alkalinizing agent, and in conditions in which IV administration of the drug is not necessary (e.g., alkalinization of the urine).

IV Administration

Irrigate IV tubing with a 5- to 10-mL bolus of 0.9% sodium chloride injection following administration; such irrigation of the IV tubing should routinely be performed in between administration of any drugs used to resuscitate patients with cardiac arrest.

Dilution

Premature infants and neonates: Use a 1:1 dilution of 7.5 or 8.4% sodium bicarbonate injection and 5% dextrose injection to avoid hypertonicity; alternatively, a commercially available 4.2% solution may be used. There is no evidence that such dilute solutions are beneficial in older infants or children.

Rate of Administration

Neonates and children <2 years of age: Administer hypertonic sodium bicarbonate injections by slow IV infusion of a 4.2% solution (up to 8 mEq/kg daily).

Dosage

Each 84 mg or 1 g of sodium bicarbonate contains 1 or about 12 mEq, respectively, each of sodium and bicarbonate ions.

Pediatric Patients

Metabolic Acidosis

IV

Older children: 2–5 mEq/kg as an infusion over 4–8 hours in less urgent forms of metabolic acidosis. Subsequent doses should be determined by the response of the patient and appropriate laboratory determinations.

Plan sodium bicarbonate therapy in a stepwise manner, since the degree of response following a given dose is not always predictable. Reduce dose and frequency of administration after severe symptoms have improved.

Cardiopulmonary Resuscitation

IV or Intraosseous Injection

Infants and children: Initially, 1 mEq/kg (1 mL/kg of an 8.4% sodium bicarbonate solution).†

Ensure adequate alveolar ventilation during cardiac arrest and administration of sodium bicarbonate, since adequate ventilation contributes to the correction of acidosis and administration of sodium bicarbonate is followed by release of carbon dioxide.†

In the post-resuscitation phase, determine dosage by measurements of arterial blood pH and PaCO₂ and calculation of base deficit. If blood gas tensions and pH measurements are available, subsequent doses should be determined by the following equation:

mEq NaCHO₃ = 0.3 × bodyweight (in kg) × base deficit (in mEq/L)

Alkalinization of Urine

Oral

1–10 mEq (84–840 mg) per kg daily, adjusted according to response.

Adults

Metabolic Acidosis

IV

Initially, administer no more than 33–50% of the calculated bicarbonate requirements when initial, rapid administration of the drug is considered necessary. Consult specialized references on fluid and electrolyte and acid-base balance for specific recommendations.

2–5 mEq/kg dose as an infusion over 4–8 hours in less urgent forms of metabolic acidosis. Subsequent doses should be determined by the response of the patient and appropriate laboratory determinations. Therapy should be planned in a stepwise manner, since the degree of response following a given dose is not always predictable. Generally, the dose and frequency of administration should be reduced after severe symptoms have improved.

Diabetic Ketoacidosis

IV

Partially correct acidosis, generally to an arterial pH of about 7.2, in order to avoid rebound alkalosis.

Cardiopulmonary Resuscitation

IV

Initially, 1 mEq/kg. Administer additional doses of up to 0.5 mEq/kg at 10-minute intervals during continued arrest.

Ensure adequate alveolar ventilation during cardiac arrest and administration of sodium bicarbonate, since adequate ventilation contributes to the correction of acidosis and administration of sodium bicarbonate is followed by release of carbon dioxide.

In the post-resuscitation phase, determine dosage by measurements of arterial blood pH and PaCO₂ and calculation of base deficit. If blood gas tensions and pH measurements are available, subsequent doses should be determined by the following equation:

mEq NaCHO₃ = 0.3 × bodyweight (in kg) × base deficit (in mEq/L)

Acidosis Associated with Chronic Renal Failure

Oral

Initially, 20–36 mEq daily, given in divided doses when plasma bicarbonate concentration is less than 15 mEq/L. Titrate dosage to provide a plasma bicarbonate concentration of about 18–20 mEq/L. To relieve symptoms and prevent or stabilize renal failure and osteomalacia in patients with renal tubular acidosis, higher dosages of sodium bicarbonate are necessary.

Distal (type 1) renal tubular acidosis: Initially, 0.5–2 mEq/kg daily, given in 4 or 5 divided doses. Titrate dosage until hypercalciuria and acidosis are controlled, and according to the response and tolerance of the patient. Alternatively, 48–72 mEq (about 4–6 g) daily.

Proximal (type 2) renal tubular acidosis: 4–10 mEq/kg daily, given in divided doses.

Alkalinization of Urine

Oral

Initially, 48 mEq (4 g), followed by 12–24 mEq (1–2 g) every 4 hours. Dosages of 30–48 mEq (2.5–4 g) every 4 hours, up to 192 mEq (16 g) daily, may be required in some patients. Titrate dosage to maintain the desired urinary pH.