What is the starting dose and rate for a sodium bicarbonate (NaHCO3) drip in a patient with severe acidosis after cardiac arrest?

From the Guidelines

For a patient with severe acidosis after cardiac arrest, the recommended starting dose for a sodium bicarbonate (NaHCO3) drip is typically 1 mEq/kg administered intravenously. This dose is based on the most recent and highest quality study available, which suggests that routine use of sodium bicarbonate is not recommended for patients in cardiac arrest, but may be beneficial in special situations such as preexisting metabolic acidosis, hyperkalemia, or tricyclic antidepressant overdose 1. The use of sodium bicarbonate should be guided by the bicarbonate concentration or calculated base deficit obtained from blood gas analysis or laboratory measurement, and providers should not attempt complete correction of the calculated base deficit to minimize the risk of iatrogenically induced alkalosis 1. Some key points to consider when administering sodium bicarbonate include:

• Monitoring serum electrolytes, particularly sodium and potassium, as bicarbonate administration can cause hypokalemia and hypernatremia
• Continuous cardiac monitoring is essential as rapid correction of acidosis can lead to arrhythmias
• The rationale for sodium bicarbonate administration is to buffer excess hydrogen ions in severe metabolic acidosis, which can impair cardiac contractility, decrease responsiveness to catecholamines, and cause vasodilation leading to hypotension
• Bicarbonate therapy should be used judiciously as it can potentially worsen intracellular acidosis and cause volume overload 1. It's also important to note that other non–CO2-generating buffers such as bicarb, THAM, or tribonate have shown potential for minimizing some adverse effects of sodium bicarbonate, but clinical experience is greatly limited and outcome studies are lacking 1. In terms of preparation, the concentration of the infusion is usually prepared as 150 mEq of sodium bicarbonate in 1000 mL of D5W or sterile water, resulting in a solution of 150 mEq/L, and titration should be based on serial arterial blood gas measurements, with a goal of gradually normalizing pH to above 7.2 1.

From the FDA Drug Label

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.

The starting dose for a sodium bicarbonate (NaHCO3) drip in a patient with severe acidosis after cardiac arrest is 1 to 2 syringes of 50 mL (44.6 to 100 mEq), and the rate can be continued at 50 mL (44.6 to 50 mEq) every 5 to 10 minutes as needed, based on arterial pH and blood gas monitoring 2.

• The dose and rate should be adjusted according to the patient's response and clinical condition.
• Monitoring of blood gases, plasma osmolarity, arterial blood lactate, hemodynamics, and cardiac rhythm is crucial in guiding the therapy.
• The goal is to improve the acid-base status of the blood without causing undue side effects, such as alkalosis.

From the Research

Starting Dose and Rate for Sodium Bicarbonate Drip

The starting dose and rate for a sodium bicarbonate (NaHCO3) drip in a patient with severe acidosis after cardiac arrest is not explicitly stated in the provided studies. However, some studies provide information on the use of sodium bicarbonate in cardiac arrest patients:

• A study published in 1995 3 used 1 mmol/kg of sodium bicarbonate initially, and base deficit was corrected to -5 mmol/L with additional bicarbonate in a canine model of cardiac arrest.
• Another study published in 2018 4 administered sodium bicarbonate to patients with severe metabolic acidosis during prolonged cardiopulmonary resuscitation, but the dose and rate are not specified.

Key Considerations

When considering the use of sodium bicarbonate in cardiac arrest patients, the following points are important:

• The American Heart Association no longer recommends the routine use of sodium bicarbonate in cardiac arrests due to the lack of documented effect on clinical outcome and potential adverse effects of metabolic alkalosis and hypernatremia 5.
• Sodium bicarbonate may improve acid-base status, but its effect on the rate of return of spontaneous circulation (ROSC) and good neurologic survival is unclear 4.
• The use of sodium bicarbonate should be individualized and based on the patient's specific condition, including the severity of acidosis and the presence of other metabolic disturbances 6.

Dosing and Administration

While there is no clear consensus on the starting dose and rate for sodium bicarbonate in cardiac arrest patients, the following general principles can be applied:

• The dose of sodium bicarbonate should be titrated to correct the base deficit and improve acid-base status.
• The rate of administration should be slow and cautious to avoid rapid changes in pH and electrolyte levels.
• Close monitoring of the patient's vital signs, electrolytes, and acid-base status is essential to guide the use of sodium bicarbonate 3, 7.