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HWN Suggests

Stop Giving Amps of Bicarb!

Sodium bicarbonate doesn't just magically raise pH...Remember this thing? CO2 + H20 <=> H2CO3 <=> HCO3 + H. It's complicated. Bicarb binds to acid. Then it turns to CO2 and water, so you can breathe it out.

Basically if you're giving bicarb, you can only raise your pH as long as you can breathe off your CO2, increasing your RATE or VOLUME. **This is particularly a problem in patients who are not in control of their breathing (vented), aren't breathing (arrest), or who have maximized the efficiency of their breathing (Kussmal breathing in DKA).**

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Featured

 Bicarb in Cardiac Arrest

Use of sodium bicarbonate as empiric therapy in cardiac arrest has been an area of controversy. During cardiac arrest hypoxia and hypoperfusion results in severe metabolic acidosis and subsequent impaired myocardial contractility, decreased efficacy of vasopressors, and increased risk of dysrhythmias. Previous ACLS guidelines recommended use of sodium bicarbonate to mitigate these effects; however, harms are also associated with its routine use including compensatory respiratory acidosis, hyperosmolarity, increased vascular resistance, and reduction in ionized calcium. Current guidelines no longer recommend routine use of sodium bicarbonate, except in cases of arrest secondary to hyperkalemia, TCA overdose or preexisting metabolic acidosis. Regardless of these recommendations, sodium bicarbonate continues to be utilized during routine management of cardiac arrest, and studies are limited in investigating its appropriate use.

 PulmCrit: pH-guided fluid resuscitation & BICAR-ICU PulmCrit: pH-guided fluid resuscitation & BICAR-ICU

The use of bicarbonate is a source of eternal disagreement. Bicarbonate has a shameful history of being abused in situations where it’s unhelpful (e.g. cardiac arrest). This has impugned its reputation, giving it an aura of ignorance and failure. Consequently, bicarbonate is underutilized in some situations where it might actually help.

 Sodium Bicarbonate Use

It is generally better to correct underlying cause of acidosis and give supportive care than to give sodium bicarbonate

 ToxCard: Sodium Bicarbonate for Toxicology – When to Use It and Why!

Sodium bicarbonate can be a useful therapy in toxic ingestions of multiple compounds including: sodium channel blocking agents, salicylates and toxic alcohols.

Articles of Interest

Bicarbonate for Respiratory Acidosis: Not So Fast

We all like to make the numbers pretty in our critically ill patient. Euboxic is a term that is thrown out there. It’s like there’s a check box in our brains that we need to fill in when turning a lab value back to the default color rather than red in our EMR. But one …

Emergent treatment of hyponatremia or elevated ICP with bicarb ampules

When hypertonic therapy is needed, it is often needed immediately. A patient with herniation or hyponatremic seizures needs hypertonic therapy now, not in ten minutes when it arrives from pharmacy. For example, I once ordered a head CT and hypertonic saline for a patient with suspected herniation, but the hypertonic saline arrived in the ICU after the patient had already left for CT scan. Hypertonic sodium bicarbonate may provide a solution to this logistical problem.

Say Bye Bye Bicarb for Pediatric In-Hospital Cardiac Arrest

The latest guidelines from the AHA in 2020 state, “clinical trials and observational studies since the 2010 guidelines have yielded no new evidence that routine administration of sodium bicarbonate improves outcomes from undifferentiated cardiac arrest and evidence suggests that it may worsen survival and neurological recovery.”

Sodium Bicarb in Cardiac Arrest

Bicarbonate use is still relatively common during cardiac arrest. Although there are various indications for bicarb use, the evidence has not proven it to be beneficial in cardiac arrest.

Sodium Bicarbonate for cardiac arrest: Time to put it away

Sodium Bicarbonate (SB) is one of those drugs used in the management of cardiac arrest that has the ability to stay in common practice despite plenty of literature over several years showing little to no benefit and perhaps harm.

Sodium Bicarbonate in Cardiac Arrest

Grand Rounds May 2021...

Sodium Bicarbonate in Cardiac Arrest Management

The use of NaHCO3 does not appear to improve clinically meaningful outcomes. A larger study should be undertaken to further evaluate this clinical question.

Sodium Bicarbonate Therapy Does Not Work in Cardiac Arrest

The theory behind using sodium bicarbonate in cardiac arrest seems to be that the severe acidosis resulting from global hypoperfusion causes decreased responsiveness to catecholamines – i.e. your epinephrine pushes won’t work – and an increased risk of dysrhythmias – i.e. that VF won’t quit. However, again, these theoretical harms of acidosis are primarily based on animal and in vitro studies. When you look at the human trials studying the use of sodium bicarbonate in cardiac arrest, they show no benefit and even possible harm. To date there are only two RCTs using sodium bicarbonate in cardiac arrest, and both showed no benefit.

Sodium Bicarbonate: Supply Shortages and Medical Shortcomings

We’re familiar with sodium bicarbonate as a simple buffer solution, which has been utilized for a myriad of medical indications backed up by physiologic rationale and occasional moderate-quality evidence. It comes in two forms; vials (typically for infusions) and pre-filled syringes (pushed in cardiac arrest). There have been on-an-off shortages of these formulations over the past several years, sparking a renewed debate over bicarb’s utility in modern medicine. This post will highlight the rationale and evidence for sodium bicarbonate in cardiac arrest, severe metabolic acidosis, and rhabdomyolysis, as it pertains to our management in the ED.

The beef with Bicarb Part 3. The Use of Sodium Bicarbonate in Cardiac Arrest

Why this topic. Something we commonly do without much evidence to support its use.

The Downside of Sodium Bicarbonate for Metabolic Acidosis (and Other Pearls)

To be sure, it is absolutely warranted in certain toxicology cases to treat with sodium bicarbonate. One review noted that repletion is indicated in cases in which metabolic acidosis is from ongoing loss of bicarbonate, say from diarrhea or renal tubular acidosis. Bicarbonate can also be used as an infusion to increase excretion and decrease tissue levels of specific poisons such as salicylate, and as a bolus to decrease prolonged QRS intervals from sodium channel-blocking drugs such as tricyclic antidepressants. The authors of this article recommend administering sodium bicarbonate if the arterial pH is 7.0 or less with a goal of increasing it to 7.2.

Use of Sodium Bicarbonate in Cardiac Arrest: Current Guidelines and Literature Review

At the present time, there is a trend against using bicarbonates in cardiac arrest, and this trend is supported by guidelines published by professional societies and organizations.

Your Patient In Extremis: THAM To The Rescue?

One thing is clear, sodium bicarbonate is not the hero we have been searching for. Unfortunately, the buffer we all know and want to love is ineffective in producing any significant change that will alter outcomes in the setting of the acutely acidemic patient.

Resources

Sodium Bicarbonate Drip

1 liter D5W, remove 150 ml from bag. 3 ampules of 8.4% NaHCO3 (50 mEq each in 50 ml), inject each into the D5W bag