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 ACLS. May be useful in some resuscitation situations (e.g., preexisting metabolic acidosis, hyperkalemia, tricyclic antidepressant overdosage, sodium-channel blocking agent toxicity, prolonged cardiac arrest).
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.
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
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
Infants and children: Initially, 1 mEq/kg (1 mL/kg of an 8.4% sodium bicarbonate solution).
Drug-induced cardiovascular emergencies (tricyclic antidepressant or other sodium-channel blocking agent toxicity): 1–2 mEq/kg by direct IV injection until the arterial pH >7.45, then infuse 150 mEq/L in 5% dextrose injection to maintain alkalosis; in severe intoxication, the pH has been increased to 7.5–7.55.
Ventricular arrhythmias associated with cocaine toxicity: 1–2 mEq/kg.
Intraosseous
Infants and children: Initially, 1 mEq/kg (1 mL/kg of an 8.4% sodium bicarbonate solution).†
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.
Drug-induced cardiovascular emergencies (tricyclic antidepressant or sodium-channel blocking agent [e.g., procainamide, flecainide] toxicity): 1–2 mEq/kg by repeated direct IV injections to maintain an arterial pH of 7.45–7.55. Maintenance infusion of 150 mEq/L plus 30 mEq of potassium chloride per liter in 5% dextrose injection recommended. For acute decompensation, may administer sodium bicarbonate direct IV injections without determining serum pH, if QRS interval >100 msec or hypotension develops.
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.
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.
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