Bicarbonate Drip for Severe Acidosis

For severe metabolic acidosis with pH < 6.9, administer sodium bicarbonate at 1-2 mEq/kg IV given slowly over 1 hour. 1

Indications for Bicarbonate Therapy

Sodium bicarbonate is indicated for treatment of metabolic acidosis in severe renal disease, uncontrolled diabetes, circulatory insufficiency due to shock, severe dehydration, cardiac arrest, and severe primary lactic acidosis 2
Bicarbonate therapy is recommended for patients with severe metabolic acidosis with pH < 6.9 1, 3
For patients with pH between 6.9 and 7.0, administer 1-2 mEq/kg sodium bicarbonate over 1 hour 1
For patients with pH > 7.0, bicarbonate therapy is generally not necessary 1, 4

The standard initial dose for adults with severe metabolic acidosis is 1-2 mEq/kg IV administered slowly 5, 1
For pediatric patients, the American Academy of Pediatrics recommends 1-2 mEq/kg sodium bicarbonate over 1 hour if pH remains ≤ 7.0 after initial hydration 4

Administer sodium bicarbonate slowly to avoid rapid alkalinization 5
For sodium channel blocker toxicity, a bolus of 50-150 mEq followed by an infusion of 150 mEq/L solution at 1-3 mL/kg/h is recommended 5

Monitor serum bicarbonate every 2-4 hours during active bicarbonate infusion therapy 1
Follow venous pH and anion gap to monitor resolution of acidosis 1
Continue sodium bicarbonate infusion until serum bicarbonate reaches ≥22 mmol/L or pH rises above 7.0 1
Ensure effective ventilation is established before administering bicarbonate, as ventilation is needed to eliminate excess CO2 produced 5, 1

Bicarbonate therapy can cause extracellular alkalosis, shifting the oxyhemoglobin curve and inhibiting oxygen release 5, 1
It can lead to hypernatremia, hyperosmolarity, and excess CO2 production causing paradoxical intracellular acidosis 5, 1
Bicarbonate can inactivate simultaneously administered catecholamines 5, 1
Do not mix sodium bicarbonate with vasoactive amines or calcium 5
Overzealous bicarbonate therapy can cause severe hypocalcemia 4

For DKA patients with pH > 7.0, no bicarbonate therapy is required 4
For pediatric DKA patients, if pH remains ≤ 7.0 after initial hydration, administer 1-2 mEq/kg sodium bicarbonate over 1 hour 4
Studies have shown no significant difference in time to resolution of acidosis or time to hospital discharge for DKA patients with initial pH < 7.0 who received bicarbonate versus those who did not 6

Routine use of bicarbonate is not supported for sepsis-related acidosis, particularly when arterial pH is > 7.15 5, 1

Bicarbonate therapy may yield improvement in survival for patients with severe metabolic acidosis accompanied by acute kidney injury 7

Prospective randomized studies have failed to show beneficial effects of bicarbonate therapy in DKA patients with pH between 6.9 and 7.1 4
No prospective randomized studies concerning bicarbonate use in DKA with pH values < 6.9 have been reported 4
Recent research suggests limited benefit from bicarbonate therapy for patients with severe metabolic acidosis (pH < 7.1 and bicarbonate < 6 mEq/L), except in cases with accompanying acute kidney injury 7