Is it appropriate to administer D5 (5% dextrose) half normal saline with 3 ampules (A) of sodium bicarbonate?

From the Guidelines

It is not appropriate to administer D5 (5% dextrose) half normal saline with 3 ampules (A) of sodium bicarbonate due to potential precipitation and chemical instability. The administration of sodium bicarbonate in D5 half normal saline is not recommended as it can cause incompatibility issues, leading to reduced efficacy or adverse reactions 1. Instead, sodium bicarbonate should be administered separately, either through different IV lines or by giving the bicarbonate as a separate infusion after temporarily stopping the D5 half normal saline. Key considerations for sodium bicarbonate administration include:

• The patient's acid-base status
• Calculated deficit
• Clinical condition
• Standard concentration for IV sodium bicarbonate is typically 8.4% (1 mEq/mL) for adults
• Dosage recommendations, such as 1 to 2 mEq/kg intravenous boluses of sodium bicarbonate until arterial pH is >7.45, as suggested by the American Heart Association guidelines 1. In pediatric patients, sodium bicarbonate can be added to NaCl, with any required potassium, to produce a solution that does not exceed 155 mEq/l sodium, if the pH remains below 7.0 after initial hydration 1. However, the most recent and highest quality study, which is the 2010 American Heart Association guidelines, should be prioritized when making decisions about sodium bicarbonate administration 1.

From the FDA Drug Label

The addition of sodium bicarbonate to parenteral solutions containing calcium should be avoided, except where compatibility has been previously established. Additives may be incompatible; norepinephrine and dobutamine are incompatible with sodium bicarbonate solution NOTE: Do not use the injection if it contains precipitate. Additives may be incompatible. Consult with pharmacist, if available When introducing additives, consult with pharmacist, if available. When introducing additives, use aseptic technique, mix thoroughly and do not store.

The administration of D5 (5% dextrose) half normal saline with 3 ampules (A) of sodium bicarbonate is not recommended without consulting a pharmacist to ensure compatibility of the additives, as the label warns that additives may be incompatible 2.

From the Research

Administration of D5 with Sodium Bicarbonate

• The administration of D5 (5% dextrose) with sodium bicarbonate is a topic of interest in critical care medicine, particularly in the context of treating metabolic acidosis 3, 4.
• Studies have investigated the stability of sodium bicarbonate in various solutions, including normal saline and 5% dextrose 3, 4.
• One study found that when 100 mL of 8.4% sodium bicarbonate were diluted in 150 mL of 5% dextrose within a 250 mL polyolefin bag, clinicians were unable to correctly identify the contents of the bags, implying that sodium bicarbonate therapy can be successfully blinded 4.
• However, the use of half normal saline (0.45% saline) has been shown to have significant effects on serum electrolytes, including a decrease in corrected serum sodium and a reduction in hyperchloremia leading to nonanion gap acidosis 5.

Considerations for Fluid Therapy

• The choice of fluid for resuscitation in pediatric patients, particularly those with diabetic ketoacidosis (DKA), is a matter of debate 5, 6, 7.
• Normal saline (0.9% saline) is commonly used, but its administration has been associated with complications such as hyperchloremic acidosis, dysnatremia, and neurologic damage 6, 7.
• Balanced electrolyte solutions may be a viable alternative to normal saline, but more research is needed to compare their effects in the pediatric acute care setting 7.
• The use of hypertonic saline solutions, such as 3% saline, has also been investigated, but its benefits and risks must be carefully considered, particularly with regard to the potential for hypernatremia, hyperchloremia, and hyperchloremic metabolic acidosis 6.

Implications for D5 with Sodium Bicarbonate Administration

• While there is no direct evidence to support or refute the administration of D5 with 3 ampules of sodium bicarbonate, the available studies suggest that careful consideration must be given to the choice of fluid and electrolyte therapy in critically ill patients 3, 4, 5, 6, 7.
• The potential benefits and risks of administering D5 with sodium bicarbonate must be weighed, taking into account the patient's individual needs and the potential for complications such as hyperchloremic acidosis and electrolyte imbalances.