What are the indications for sodium bicarbonate (NaHCO3) infusion?

From the Guidelines

Sodium bicarbonate (NaHCO3) infusion is indicated in severe metabolic acidosis, particularly in patients with a pH level below 7.1, as well as in the treatment of hyperkalemia, tricyclic antidepressant overdose, and certain cases of salicylate poisoning 1. The recommended dose is 1 mEq/kg of sodium bicarbonate, administered intravenously over 15-30 minutes, with the option to repeat as needed to achieve a target pH 1. In cases of hyperkalemia, the dose can be repeated every 10-15 minutes, up to a maximum of 3 doses, if the patient's potassium level remains elevated.

• Key Indications:
  • Severe metabolic acidosis (pH < 7.1)
  • Hyperkalemia
  • Tricyclic antidepressant overdose
  • Salicylate poisoning
• Recommended Dose:
  • 1 mEq/kg IV over 15-30 minutes
  • Repeat as needed to achieve target pH
  • Maximum of 3 doses in hyperkalemia if potassium levels remain elevated It is essential to note that the use of sodium bicarbonate should be guided by the patient's clinical condition and laboratory results, including arterial blood gas analysis and serum electrolyte levels 1. Additionally, caution should be exercised to avoid excessive sodium and fluid overload, as well as potential decreases in serum ionized calcium 1.

From the FDA Drug Label

Sodium Bicarbonate Injection, USP is indicated 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 Sodium bicarbonate is further indicated in the treatment of certain drug intoxications, including barbiturates (where dissociation of the barbiturate-protein complex is desired), in poisoning by salicylates or methyl alcohol and in hemolytic reactions requiring alkalinization of the urine to diminish nephrotoxicity of hemoglobin and its breakdown products Sodium bicarbonate also is indicated in severe diarrhea which is often accompanied by a significant loss of bicarbonate.

The indications for sodium bicarbonate (NaHCO3) infusion are:

• Metabolic acidosis due to:
  • Severe renal disease
  • Uncontrolled diabetes
  • Circulatory insufficiency due to shock or severe dehydration
  • Extracorporeal circulation of blood
  • Cardiac arrest
  • Severe primary lactic acidosis
• Drug intoxications, including:
  • Barbiturates
  • Salicylates
  • Methyl alcohol
• Hemolytic reactions requiring alkalinization of the urine
• Severe diarrhea with significant loss of bicarbonate 2

From the Research

Indications for Sodium Bicarbonate (NaHCO3) Infusion

The indications for sodium bicarbonate infusion are based on the treatment of severe metabolic acidosis. The following are some of the key points to consider:

• Severe metabolic acidosis is defined by a pH < 7.2 with HCO3- < 8 mEq/L in plasma 3
• Sodium bicarbonate infusion is indicated for the treatment of severe metabolic acidosis, particularly in patients with acute kidney injury 4, 5
• The use of sodium bicarbonate should be individualized and based on a risk-benefit assessment, considering its potential complications such as hypernatremia, hypokalemia, ionic hypocalcemia, rebound alkalosis, and intracellular acidosis 3, 6
• Sodium bicarbonate therapy may be beneficial in patients with severe metabolic acidosis and accompanying acute kidney injury, as it may improve survival 4, 5
• The following conditions may benefit from sodium bicarbonate therapy:
  • Severe metabolic acidosis with pH < 7.0 6
  • Acute kidney injury with severe metabolic acidosis 4, 5
  • Cardiac arrest secondary to sodium channel blockade or hyperkalemia 7
  • Nongap acidosis 7
• The use of sodium bicarbonate should be reserved for conditions with clear benefit to patients, and empiric use in patients with nontoxicologic causes of metabolic acidosis is not warranted 7

Key Considerations

• The administration of sodium bicarbonate requires careful monitoring of the patient's internal environment, including arterial blood gases, plasma electrolytes, and ionized calcium 3
• Isotonic solutions should be preferred instead of hypertonic bicarbonate 3
• The development of hypernatremia must be prevented, and calcium must be provided for hypocalcemia to improve cardiovascular function 3
• In mechanically ventilated patients, a respiratory response similar to the one that would develop physiologically must be established to be able to extract excess CO2 and thus avoid intracellular acidosis 3