What is the role of sodium bicarbonate administration in treating acidosis caused by respiratory arrest?

From the Guidelines

Sodium bicarbonate administration is not recommended as a routine treatment for acidosis caused by respiratory arrest, and its use should be reserved for severe, persistent metabolic acidosis that does not respond to proper ventilation. In respiratory arrest, the primary intervention should be immediate restoration of ventilation through basic and advanced airway management, including intubation and mechanical ventilation when necessary. The acidosis in respiratory arrest is primarily respiratory in nature due to carbon dioxide retention, and providing adequate ventilation will correct this by removing excess CO2.

Key Considerations

• The use of sodium bicarbonate can produce paradoxical intracellular acidosis, excess sodium load, hyperosmolarity, and can shift the oxygen-hemoglobin dissociation curve, making oxygen release to tissues more difficult 1.
• When bicarbonate combines with acid, it produces carbon dioxide, which can worsen intracellular acidosis if ventilation is inadequate 1.
• Focus should remain on high-quality CPR, proper ventilation, treating the underlying cause of arrest, and following ACLS protocols rather than early bicarbonate administration 1.

Special Situations

• Sodium bicarbonate may be considered in special situations, such as preexisting metabolic acidosis, hyperkalemia, or tricyclic antidepressant overdose, with an initial dose of 1 mEq/kg 1.
• In these situations, bicarbonate therapy should be guided by the bicarbonate concentration or calculated base deficit obtained from blood gas analysis or laboratory measurement, and providers should not attempt complete correction of the calculated base deficit 1.

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.

Sodium bicarbonate administration is indicated for metabolic acidosis caused by cardiac arrest.

• The use of sodium bicarbonate in this context is to minimize risks inherent to the acidosis itself.
• Vigorous bicarbonate therapy is required in cardiac arrest to rapidly increase plasma total CO2 content 2.

From the Research

Sodium Bicarbonate Administration for Acidosis Caused by Respiratory Arrest

• The use of sodium bicarbonate in the treatment of acidosis caused by respiratory arrest is a topic of ongoing debate 3, 4.
• A study published in 1993 suggested that the use of buffer agents, including sodium bicarbonate, is controversial and that more research is needed to determine its effectiveness 3.
• Another study published in 2021 found that early administration of sodium bicarbonate was associated with improved outcomes in patients with metabolic acidosis, but the results were not conclusive 5.
• A review published in 2021 stated that there is a lack of clinical evidence to support the use of sodium bicarbonate for respiratory acidosis and that it may even be harmful 4.
• However, a more recent study published in 2024 found that sodium bicarbonate administration improved ventilatory efficiency in experimental respiratory acidosis, which may have clinical implications 6.
• The treatment of acidosis caused by respiratory arrest should be based on the underlying cause of the acidosis and the patient's individual needs, and may involve a combination of therapies including ventilation, chest compressions, and medication 3, 7.

Key Considerations

• The use of sodium bicarbonate should be carefully considered and based on the patient's individual needs and the underlying cause of the acidosis 3, 4.
• The treatment of acidosis caused by respiratory arrest should prioritize adequate ventilation and effective chest compressions 3.
• Further research is needed to determine the effectiveness of sodium bicarbonate in the treatment of acidosis caused by respiratory arrest 3, 4.