Maximum Recommended Dose for Sodium Bicarbonate Push
The maximum recommended dose for a sodium bicarbonate push is 1-2 mEq/kg (1-2 mL/kg of 8.4% solution), which should not exceed 6 mEq/kg total to avoid severe adverse effects. 1
Dosing Guidelines for Sodium Bicarbonate Administration
Adult Dosing
- Initial bolus: 1-2 mEq/kg (1-2 mL/kg of 8.4% solution) given slowly IV/IO 1
- For cardiac arrest: 50 mL (44.6-50 mEq) may be given initially and continued at 50 mL every 5-10 minutes if necessary 2
- Maximum total dose: Should not exceed 6 mEq/kg to avoid hypernatremia, fluid overload, and cerebral edema 3
Pediatric Dosing
- Initial bolus: 1-2 mEq/kg given slowly IV/IO 1
- For newborn infants: Only 0.5 mEq/mL concentration should be used; dilution of available stock solutions may be necessary 1
- Do not administer via endotracheal tube 1
Indications for Sodium Bicarbonate Administration
Sodium bicarbonate push is indicated for:
- Metabolic acidosis 1
- Hyperkalemia 1
- Sodium channel blocker toxicity (e.g., tricyclic antidepressant overdose) 1, 3
- Ventricular arrhythmias associated with cocaine toxicity 1
Administration Technique
- Administer slowly as a bolus for cardiac arrest 1
- For less urgent forms of metabolic acidosis, administer over 4-8 hours 2
- For sodium channel blocker poisoning, administer in conjunction with mechanical ventilation and hyperventilation to achieve serum alkalinization (PCO₂ ~30-35 mmHg) and a pH of ~7.45-7.55 3
- Do not mix sodium bicarbonate with vasoactive amines or calcium 1, 4
Monitoring and Precautions
- Monitor arterial pH and blood gas during administration 2
- Monitor for electrolyte abnormalities, particularly hypokalemia and hypocalcemia 3
- Observe for signs of hypernatremia and metabolic alkalosis 2, 3
- For sodium channel blocker toxicity, monitor ECG changes, particularly QRS duration 3
Important Considerations and Pitfalls
- Caution with rapid infusion of large quantities of bicarbonate as it can cause hypernatremia 2
- In cardiac arrest, the risks from acidosis generally exceed those of hypernatremia 2
- Excessive doses (>6 mEq/kg) can cause hypernatremia, fluid overload, metabolic alkalosis, and cerebral edema 3
- Response to sodium bicarbonate varies among different sodium channel blockers; tricyclic antidepressants respond well, while others like bupropion may not 3
- Routine initial use of sodium bicarbonate to treat cardiac arrest is not recommended; it should be used after effective ventilation has been established 1
- For sodium channel blocker poisoning, do not continue dosing just to normalize QRS duration, as this may lead to overdosing 3
By following these guidelines, clinicians can safely administer sodium bicarbonate while minimizing the risk of adverse effects associated with excessive dosing.