How do you prepare a sodium bicarbonate (bicarb) drip with 1L of Normal saline (0.9% sodium chloride solution)?

Preparing a Sodium Bicarbonate Drip with 1L Normal Saline

Standard Preparation Method

Add 100-150 mEq of sodium bicarbonate (100-150 mL of 8.4% solution) to 1L of 0.9% normal saline to create an isotonic bicarbonate solution for continuous infusion. This preparation is commonly used for ongoing alkalinization in sodium channel blocker toxicity, severe metabolic acidosis requiring sustained therapy, or contrast-induced AKI prevention 1.

Step-by-Step Preparation Protocol

Materials Required

• 1L bag of 0.9% normal saline (154 mEq/L sodium) 2
• 100-150 mL of 8.4% sodium bicarbonate injection (1 mEq/mL) 3
• Polyolefin IV bag (preferred for stability) 4

Preparation Steps

• Remove approximately 100-150 mL of normal saline from the 1L bag to make room for the bicarbonate addition 1
• Add 100-150 mEq (100-150 mL) of 8.4% sodium bicarbonate to the remaining normal saline using aseptic technique 1, 4
• Mix thoroughly by gently inverting the bag several times 4
• Label the bag clearly with final concentration (approximately 150 mEq/L bicarbonate), date/time of preparation, and expiration 4

Final Solution Characteristics

The resulting solution contains approximately:

• 150 mEq/L of bicarbonate when 150 mEq is added 1
• Total sodium concentration of ~220-240 mEq/L (from both normal saline and bicarbonate) 2
• pH of approximately 7.5-8.0 4

Stability and Storage

• Refrigerated storage (2-4°C): Stable for up to 7 days 4, 5
• Room temperature storage (21-24°C): Stable for 48 hours when prepared as described 4, 5
• The bicarbonate concentration remains stable over 48 hours in polyolefin bags, though pH and PCO2 decrease slightly 4

Administration Guidelines

Infusion Rates

• Standard continuous infusion: 1-3 mL/kg/hour for ongoing alkalinization in sodium channel blocker toxicity 1
• Adjust rate based on arterial blood gas monitoring every 2-4 hours 1
• Target pH of 7.45-7.55 for toxicologic indications, or 7.2-7.3 for metabolic acidosis 1

Critical Safety Precautions

• Never mix with calcium-containing solutions in the same line, as precipitation will occur 1
• Never mix with catecholamines (norepinephrine, epinephrine, dobutamine) in the same line, as bicarbonate inactivates these medications 1
• Flush IV line with normal saline before and after bicarbonate administration if other medications are being given 1

Monitoring Requirements During Infusion

• Arterial blood gases every 2-4 hours to assess pH, PaCO2, and bicarbonate response 1
• Serum sodium every 2-4 hours to prevent hypernatremia (target <150-155 mEq/L) 1
• Serum potassium every 2-4 hours, as bicarbonate shifts potassium intracellularly and can cause severe hypokalemia 1
• Ionized calcium levels with large doses, as bicarbonate can decrease ionized calcium 1

Alternative Preparation for Specific Indications

For Contrast-Induced AKI Prevention

The KDIGO guidelines reference isotonic bicarbonate preparation, though no commercially available premixed isotonic bicarbonate solutions exist in the United States 1. The preparation described above (150 mEq in 1L) approximates an isotonic solution, though evidence for benefit over normal saline alone is equivocal 6, 7.

For Pediatric Patients

• Dilute 8.4% bicarbonate 1:1 with normal saline to achieve 4.2% concentration (0.5 mEq/mL) for children under 2 years 1
• Never use 8.4% solution undiluted in newborns or infants 1

Common Pitfalls to Avoid

• Do not use dextrose-containing solutions as the primary diluent for continuous infusions, as this increases osmolality and risk of hyperglycemia, though D5W is compatible with bicarbonate 8
• Do not prepare in glass containers, as polyolefin bags provide better stability 4
• Do not exceed serum sodium of 150-155 mEq/L during therapy, as this increases risk of osmotic complications 1
• Ensure adequate ventilation before and during bicarbonate infusion, as CO2 production increases and requires elimination 1