Sodium Bicarbonate

Name: Sodium Bicarbonate

Dosing & Uses

Dosage Forms & Strengths

injectable solution

  • 4%
  • 4.2%
  • 7.5%
  • 8.4%

tablet

  • 325mg
  • 650mg

Cardiac Arrest

Initial: 1 mEq/kg/dose IV x1; base subsequent doses on results of arterial blood pH and PaCO2 as well as calculation of base deficit

Repeat doses may be considered in the setting of prolonged cardiac arrest only after adequate alveolar ventilation has been established

Hyperkalemia

50 mEq IV over 5 minutes

Metabolic Acidosis (Non-Life-Threatening)

2-5 mEq/kg IV infusion over 4-8 hr depending on the severity of acidosis as judged by the lowering of total CO2 content, clinical condition and pH

Severe Metabolic Acidosis (Except Hypercarbic Acidosis)

90 to 180 mEq/L (~ 7.5-15 g) at a rate of 1-1.5 L (first hour); adjust for further management as needed

Administration

Monitor: serum potassium

Dosage Forms & Strengths

injectable solution

  • 4%
  • 4.2%
  • 7.5%
  • 8.4%

tablet

  • 325mg
  • 650mg

Cardiac Arrest

Infants, <2 years (use 4.2% solution)

  • Initial: 1 mEq/kg/min given over 1-2 minutes IV/IO, THEN
  • 1 mEq/kg IV q10min of arrest
  • Not to exceed 8 mEq/kg/day

>2 years

  • Initial: 1 mEq/kg/dose IV x1; base subsequent doses on results of arterial blood pH and PaCO2 as well as calculation of base deficit
  • Repeat doses may be considered in the setting of prolonged cardiac arrest only after adequate alveolar ventilation has been established

Metabolic Acidosis (Non-Life-Threatening)

Older children: 2-5 mEq/kg IV infusion over 4-8 hr depending on the severity of acidosis as judged by the lowering of total CO2 content, clinical condition and pH

Administration

Monitor: serum potassium

Warnings

Contraindications

Hypersensitivity, metabolic or respiratory alkalosis, hypocalcemia, excessive Cl- loss from vomiting or GI suctioning

Patients at risk of developing diuretic-induced hypochloremic alkalosis

Hypercarbic acidosis

Unknown abdominal pain

Cautions

Not first-line for resuscitation

Edematous or Na-retaining states, history of CHF, renal impairment, cirrhosis, HTN, children with DKA, concurrent corticosteroid use

May cause hypokalemia

Use caution in patients with cirrhosis, heart failure, renal impairment, peptic ulcer disease, or edema

Avoid extravasation (may cause chemical cellulitis, tissue necrosis, ulceration & sloughing due to alkalinity)

Indications

Sodium Bicarbonate (sodium bicarbonate 5% injection) Injection may be indicated in the treatment of metabolic acidosis which can occur in severe renal disease, uncontrolled diabetes, circulatory insufficiency due to shock, anoxia or severe dehydration, extracorporeal circulation of blood and severe primary lactic acidosis. Sodium Bicarbonate (sodium bicarbonate 5% injection) Injection is further indicated in the treatment of certain drug intoxications, including barbiturates, in poisoning by salicylates or methyl alcohol, and in hemolytic reactions requiring alkalinization of the urine to diminish nephrotoxicity of blood pigments. Sodium Bicarbonate (sodium bicarbonate 5% injection) Injection may also be indicated in severe diarrhea which is often accompanied by a significant loss of bicarbonate.

What should I discuss with my healthcare provider before taking sodium bicarbonate?

Ask a doctor or pharmacist if it is safe for you to take this medicine if you have other medical conditions, especially:

  • kidney disease;

  • liver disease;

  • heart disease;

  • high blood pressure; or

  • if you are on a low salt diet.

It is not known whether sodium bicarbonate will harm an unborn baby. However, sodium bicarbonate can cause fluid to build up in your body, which may be dangerous during pregnancy. Do not use this medicine without a doctor's advice if you are pregnant.

It is not known whether sodium bicarbonate passes into breast milk or if it could harm a nursing baby. Do not use this medicine without a doctor's advice if you are breast-feeding a baby.

Description

Sodium Bicarbonate Injection, USP is a sterile, nonpyrogenic, hypertonic solution of Sodium Bicarbonate (NaHCO3) in water for injection for administration by the intravenous route as an electrolyte replenisher and systemic alkalizer.

Solutions are offered in concentrations of 7.5% and 8.4%. See table in HOW SUPPLIED section for contents and characteristics.

Solutions in the Ansyr® II syringe have an approximate pH of 8.0 (7.5 to 8.5).

The solutions contain no bacteriostat, antimicrobial agent or added buffer and are intended only for use as a single-dose injection. When smaller doses are required, the unused portion should be discarded with the entire unit.

Sodium Bicarbonate, 84 mg is equal to one milliequivalent each of Na+ and HCO3¯. Sodium Bicarbonate, USP is chemically designated NaHCO3, a white crystalline powder soluble in water.

Water for Injection, USP is chemically designated H2O.

Overdosage

Should alkalosis result, the bicarbonate should be stopped and the patient managed according to the degree of alkalosis present. 0.9% sodium chloride injection intravenous may be given; potassium chloride also may be indicated if there is hypokalemia. Severe alkalosis may be accompanied by hyperirritability or tetany and these symptoms may be controlled by calcium gluconate. An acidifying agent such as ammonium chloride may also be indicated in severe alkalosis. See WARNINGS and PRECAUTIONS.

Dosage and Administration

Sodium Bicarbonate Injection, USP is administered by the intravenous route.

In cardiac arrest, a rapid intravenous dose of one to two 50 mL syringes (44.6 to 100 mEq) may be given initially and continued at a rate of 50 mL (44.6 to 50 mEq) every 5 to 10 minutes if necessary (as indicated by arterial pH and blood gas monitoring) to reverse the acidosis. Caution should be observed in emergencies where very rapid infusion of large quantities of bicarbonate is indicated. Bicarbonate solutions are hypertonic and may produce an undesirable rise in plasma sodium concentration in the process of correcting the metabolic acidosis. In cardiac arrest, however, the risks from acidosis exceed those of hypernatremia.

In infants (up to two years of age), the 4.2% solution is recommended for intravenous administration at a dose not to exceed 8 mEq/kg/day.  Slow administration rates at the 4.2% solution are recommended in neonates, to guard against the possibility of producing hypernatremia, decreasing cerebrospinal fluid pressure and inducing intracranial hemorrhage. 

In less urgent forms of metabolic acidosis, Sodium Bicarbonate Injection, USP may be added to other intravenous fluids. The amount of bicarbonate to be given to older children and adults over a four-to-eight-hour period is approximately 2 to 5 mEq/kg of body weight - depending upon the severity of the acidosis as judged by the lowering of total CO2 content, blood pH and clinical condition of the patient. In metabolic acidosis associated with shock, therapy should be monitored by measuring blood gases, plasma osmolarity, arterial blood lactate, hemodynamics and cardiac rhythm. Bicarbonate therapy should always be planned in a stepwise fashion since the degree of response from a given dose is not precisely predictable. Initially an infusion of 2 to 5 mEq/kg body weight over a period of 4 to 8 hours will produce a measurable improvement in the abnormal acid-base status of the blood. The next step of therapy is dependent upon the clinical response of the patient. If severe symptoms have abated, then the frequency of administration and the size of the dose may be reduced.

In general, it is unwise to attempt full correction of a low total CO2 content during the first 24 hours of therapy, since this may be accompanied by an unrecognized alkalosis because of a delay in the readjustment of ventilation to normal. Owing to this lag, the achievement of total CO2 content of about 20 mEq/liter at the end of the first day of therapy will usually be associated with a normal blood pH. Further modification of the acidosis to completely normal values usually occurs in the presence of normal kidney function when and if the cause of the acidosis can be controlled. Values for total CO2 which are brought to normal or above normal within the first day of therapy are very likely to be associated with grossly alkaline values for blood pH, with ensuing undesired side effects.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. See PRECAUTIONS.

Do not use unless solution is clear and the container or seal is intact.  Discard unused portion.

Pronunciation

(SOW dee um bye KAR bun ate)

Duration of Action

Oral: 1 to 3 hours; IV: 8 to 10 minutes

Dosing Adult

Note: 1 mEq NaHCO3 is equivalent to 84 mg; each g of NaHCO3 provides ~12 mEq each of sodium and bicarbonate ions. Each oral tablet (650 mg) contains 7.7 mEq each of sodium and bicarbonate ions.

Cardiac arrest (ACLS 2010): IV: Initial: 1 mEq/kg/dose; repeat doses should be guided by arterial blood gases

Routine use of NaHCO3 is not recommended. May be considered in the setting of prolonged cardiac arrest only after adequate alveolar ventilation has been established and effective cardiac compressions. Note: In some cardiac arrest situations (eg, metabolic acidosis, hyperkalemia, or tricyclic antidepressant overdose), sodium bicarbonate may be beneficial.

Metabolic acidosis in patients with chronic kidney disease: Oral (off-label): Note: KDIGO guidelines suggest oral replacement when plasma HCO3- concentrations are <22 mEq/L (KDIGO 2013).

Initial: 15.4 to 23.1 mEq/day in divided doses (eg, 650 mg tablet 2 to 3 times daily); titrate to normal serum bicarbonate concentrations (eg, 23 to 29 mEq/L) or up to 5850 mg/day; baking soda may be used as an alternative in patients who cannot take tablets (Chen 2014; KDIGO 2013; Kovesdy 2009; Raphael 2016). Avoid exceeding serum bicarbonate concentrations >32 mEq/L since this has been associated with increased mortality in patients with CKD (Navaneethan 2011).

Metabolic acidosis: IV: Dosage should be based on the following formula if blood gases and pH measurements are available:

HCO3-(mEq) = 0.5 x weight (kg) x [24 - serum HCO3-(mEq/L)] or HCO3-(mEq) = 0.5 x weight (kg) x [desired increase in serum HCO3-(mEq/L)]

Administer 1/2 dose initially, then remaining 1/2 dose over the next 24 hours; monitor pH, serum HCO3-, and clinical status. Note: These equations provide an estimated replacement dose. The underlying cause and degree of acidosis may result in the need for larger or smaller replacement doses. In most cases, the initial goal of therapy is to target a pH of ~7.2 and a plasma bicarbonate level of ~10 mEq/L to prevent overalkalinization. According to the ARDSNet protocol, if pH remains <7.15 after ventilator adjustments, may give NaHCO3 (Brower 2004).

If acid-base status is not available: 2 to 5 mEq/kg IV infusion over 4 to 8 hours; subsequent doses should be based on patient's acid-base status.

Hyperkalemia (ACLS 2010): IV: 50 mEq over 5 minutes (as appropriate, consider methods of enhancing potassium removal/excretion)

Renal tubular acidosis: Oral:

Distal: 0.5 to 2 mEq/kg/day in 4 to 5 divided doses

Proximal: Initial: 5 to 10 mEq/kg/day; maintenance: Increase as required to maintain serum bicarbonate in the normal range

Urine alkalinization: Oral: Initial: 48 mEq (4 g), then 12 to 24 mEq (1 to 2 g) every 4 hours; dose should be titrated to desired urinary pH; doses up to 16 g/day (200 mEq) in patients <60 years and 8 g (100 mEq) in patients >60 years. Administration of 48 mEq (4 g) every 8 hours for a total daily dose of 144 mEq (12 g) has also been shown to achieve a urinary pH of at least 7 after a period of 10 hours in one study of healthy volunteers (Cohen 2013). Note: Intravenous administration is preferred in specific overdoses (eg, salicylate) with a target urinary pH of 7.5 to 8.5 (Levine 2011; Proudfoot 2004).

Antacid: Oral: 325 mg to 2 g 1 to 4 times/day

Neutralize lidocaine with epinephrine dental anesthetic: Neutralizing additive: Mix 10 parts anesthetic (lidocaine with epinephrine) to 1 part 8.4% sodium bicarbonate

Add 0.18 mL sodium bicarbonate to 1.8 mL cartridge of lidocaine 2% with epinephrine 1:50,000 or 1:100,000

Add 2 mL sodium bicarbonate to 20 mL vial of lidocaine 2% with epinephrine 1:100,000

Add 3 mL sodium bicarbonate to 30 mL vial of lidocaine 2% with epinephrine 1:100,000

Add 5 mL sodium bicarbonate to 50 mL vial of lidocaine 2% with epinephrine 1:100,000

Prevention of contrast-induced nephropathy (off-label use): IV infusion: 154 mEq/L sodium bicarbonate in D5W solution: 3 mL/kg/hour for 1 hour immediately before contrast injection, then 1mL/kg/hour during contrast exposure and for 6 hours after procedure (Merten 2004). Some have described a prophylactic strategy based on patient risk for contrast induced nephropathy and procedure type (Goldfarb 2009).

Storage

Store injection at room temperature. Protect from heat and from freezing. Use only clear solutions.

Neutralizing additive (dental use): Store at 20°C to 25°C (68°F to 77°F).

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