Sodium Bicarbonate Administration for Acidosis
Sodium bicarbonate should be administered at an initial dose of 1-2 mEq/kg given slowly intravenously for metabolic acidosis, with therapy guided by bicarbonate concentration or calculated base deficit from blood gas analysis. 1, 2
Indications for Sodium Bicarbonate
Sodium bicarbonate is not recommended for routine use in all acidotic states but is indicated in specific clinical scenarios:
- Severe metabolic acidosis (pH < 7.0)
- Hyperkalemia
- Tricyclic antidepressant overdose
- Sodium channel blocker toxicity
- Severe diarrhea with significant bicarbonate loss
- Severe renal disease with metabolic acidosis
- Drug intoxications requiring urine alkalinization (barbiturates, salicylates, methyl alcohol)
Routine use in cardiac arrest is not recommended unless associated with one of the above conditions 1, 3.
Dosing Protocol
Initial Dosing
- Standard dose: 1-2 mEq/kg IV given slowly 1, 2
- Cardiac arrest: 50-100 mEq (1-2 vials of 50 mL) rapid IV initially, then 44.6-50 mEq every 5-10 minutes as needed 2
Maintenance Dosing
- For less urgent metabolic acidosis: 2-5 mEq/kg over 4-8 hours 2
- Target total CO2 content of approximately 20 mEq/L at the end of the first day 2
Administration Method
- Administer via intravenous route only
- For cardiac arrest: rapid IV push
- For metabolic acidosis: slow infusion or addition to other IV fluids
- Do not administer via endotracheal tube 1
Monitoring During Administration
- Arterial blood gases
- Serum electrolytes (especially potassium, calcium, sodium)
- ECG
- Blood pressure
- Mental status
Monitoring should be performed before administration, during therapy, and after completion to assess response and detect complications 3, 2.
Special Considerations
Pediatric Patients
- Only use 0.5 mEq/mL concentration for newborn infants; dilution of available stock solutions may be necessary 1
- For diabetic ketoacidosis in pediatric patients: administer 1-2 mEq/kg during 1 hour if pH <7.0 after the first hour of hydration 3
Ventilated Patients
- Ensure adequate ventilation to allow elimination of excess CO2 produced by bicarbonate 1, 3
- Anticipate the need for increased minute ventilation
Potential Complications and Management
Electrolyte Disturbances
- Hypokalemia: Monitor serum potassium closely; may require potassium supplementation 3, 4
- Hypocalcemia: Monitor ionized calcium; may require calcium supplementation 3
- Hypernatremia: Use caution in patients with heart failure or sodium-retaining states 3, 5
Other Complications
- Extracellular alkalosis shifting the oxyhemoglobin curve
- Paradoxical intracellular acidosis due to CO2 generation
- Hyperosmolarity
- Reduced systemic vascular resistance affecting cardiac performance 1
Important Precautions
- Do not mix sodium bicarbonate with vasoactive amines or calcium 1
- Do not attempt complete correction of base deficit in the first 24 hours to avoid iatrogenic alkalosis 2
- Use a stepwise approach, as the degree of response from a given dose is not precisely predictable 2
- Bicarbonate therapy should always follow effective ventilation establishment in patients with respiratory component 1, 3
Recent Evidence
The most recent evidence from a 2025 target trial emulation suggests that bicarbonate administration was associated with a small but statistically significant reduction in mortality (1.9% absolute reduction) for patients with metabolic acidosis in ICU settings 6. This benefit was observed across various subgroups, including patients with acute kidney injury and those requiring vasoactive therapy.
Alternative Buffers
Other non-CO2-generating buffers such as THAM (tromethamine) may be considered to minimize some adverse effects of sodium bicarbonate, particularly in patients with mixed acidosis with high PaCO2 levels 1, 4. However, clinical experience with these alternatives is limited, and outcome studies are lacking.