From the FDA Drug Label
Sodium Bicarbonate Injection, USP is indicated in the treatment of metabolic acidosis which may occur in severe renal disease, uncontrolled diabetes, circulatory insufficiency due to shock or severe dehydration, extracorporeal circulation of blood, cardiac arrest and severe primary lactic acidosis Vigorous bicarbonate therapy is required in any form of metabolic acidosis where a rapid increase in plasma total CO2 content is crucial - e. g., cardiac arrest, circulatory insufficiency due to shock or severe dehydration, and in severe primary lactic acidosis or severe diabetic acidosis. To treat persistent unknown lactic acidosis, sodium bicarbonate (IV) may be indicated if it is a form of metabolic acidosis or severe primary lactic acidosis.
- The treatment should be superimposed on measures designed to control the basic cause of the acidosis.
- Vigorous bicarbonate therapy is required in severe cases. 1
From the Research
Treatment of persistent unknown lactic acidosis should focus on identifying and addressing the underlying cause while providing supportive care, with a particular emphasis on ensuring adequate tissue perfusion and oxygen delivery, as evidenced by the most recent study 2. The approach to treating persistent unknown lactic acidosis involves several key steps:
- Ensuring adequate tissue perfusion by administering intravenous fluids such as normal saline at 10-20 ml/kg, followed by maintenance fluids based on the patient's status.
- Optimizing oxygen delivery with supplemental oxygen to maintain saturation above 94%.
- If the patient is hemodynamically unstable, vasopressors like norepinephrine (starting at 0.05-0.1 mcg/kg/min) may be necessary.
- Correcting any electrolyte imbalances, particularly potassium, calcium, and magnesium.
- Considering the use of sodium bicarbonate (1-2 mEq/kg IV over 30-60 minutes) in severe cases with pH < 7.1, though its use remains controversial, as noted in studies 3, 4, 5. Simultaneously, it is crucial to conduct a thorough diagnostic workup including:
- Comprehensive metabolic panel
- Toxicology screening
- Evaluation for occult infection or tissue ischemia Discontinuing any medications that may contribute to lactic acidosis, such as metformin, nucleoside reverse transcriptase inhibitors, or propofol, is also essential. For patients with suspected mitochondrial disorders, a trial of thiamine (100 mg IV daily), as seen in the case report 2, riboflavin (100 mg daily), coenzyme Q10 (5-15 mg/kg/day), or L-carnitine (50-100 mg/kg/day) may be beneficial. The goal of treatment is to improve cellular metabolism and oxygen utilization while addressing the primary cause, as persistent lactic acidosis can lead to multi-organ dysfunction if left untreated, highlighting the importance of early and aggressive management 6, 5.