From the Guidelines
Sodium bicarbonate is not recommended as a routine intervention during cardiac arrest management according to current ACLS protocols, and its use should be limited to specific situations such as hyperkalemia, tricyclic antidepressant overdose, or severe metabolic acidosis. These specific situations are outlined in the guidelines as exceptions where bicarbonate can be beneficial 1. The use of sodium bicarbonate in cardiac arrest is generally discouraged due to its potential to cause more harm than good, including intracellular acidosis, decreased coronary perfusion, hypernatremia, and hyperosmolality 1.
Key Considerations for Bicarbonate Use
- The initial dose of sodium bicarbonate, when indicated, is typically 1 mEq/kg IV bolus, with subsequent doses guided by arterial blood gas results if available 1.
- Bicarbonate administration should be integrated into ACLS after establishing high-quality CPR, appropriate airway management, defibrillation for shockable rhythms, and administration of primary medications like epinephrine and amiodarone.
- The rationale for limited bicarbonate use is supported by evidence showing that routine administration may be harmful, and adequate ventilation remains the preferred method for managing acidosis during cardiac arrest 1.
Special Situations for Bicarbonate Use
- Hyperkalemia
- Tricyclic antidepressant overdose
- Severe metabolic acidosis (pH < 7.2) with prolonged resuscitation efforts In these special situations, bicarbonate can be beneficial, but its use should be guided by the bicarbonate concentration or calculated base deficit obtained from blood gas analysis or laboratory measurement, and providers should avoid attempting complete correction of the calculated base deficit to minimize the risk of iatrogenically induced alkalosis 1.
From the FDA Drug Label
In cardiac arrest, a rapid intravenous dose of one to two 50 mL vials (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.
Sodium bicarbonate is indicated in cardiac arrest to reverse acidosis, as indicated by arterial pH and blood gas monitoring. The initial dose is one to two 50 mL vials (44.6 to 100 mEq), which may be continued at a rate of 50 mL (44.6 to 50 mEq) every 5 to 10 minutes if necessary 2.
From the Research
Indications for Sodium Bicarbonate in Cardiac Arrest
According to Advanced Cardiovascular Life Support (ACLS) protocol, sodium bicarbonate is indicated in specific conditions, including:
- Hyperkalemic cardiac arrest 3, 4
- Severe cardiotoxicity 3, 4
- Overdose due to tricyclic antidepressants 3, 4
- Prolonged cardiac arrest or preexisting metabolic acidemia 5
Use of Sodium Bicarbonate in Cardiac Arrest
The use of sodium bicarbonate in cardiac arrest is currently controversial, with some studies suggesting that it may not be beneficial in improving outcomes 3, 4. The American Heart Association's revised guidelines recommend that bicarbonate be used only at the discretion of the physician directing the resuscitation 6.
Alternative Treatments
In cases of cardiac arrest due to severe diabetic ketoacidosis, insulin and fluid resuscitation is the mainstay of treatment, and extracorporeal life support (ECLS) should be considered when prolonged cardiac arrest is expected 7. Adequate ventilation and effective chest compressions must be quickly established after cardiac arrest to counterbalance the hypercarbic and metabolic acidemia of cardiac arrest 5.