Sodium Bicarbonate Injection

ADULTS

Indication	Dosing	Reference
Metabolic Acidosis (less severe)	IV: Dosage should be based on the following formula if blood gases and pH measurements are available: HCO3-(mEq) = 0.5 x weight (kg) x [24 - serum HCO3-(mEq/L)] or HCO3-(mEq) = 0.5 x weight (kg) x [desired increase in serum HCO3-(mEq/L)] Administer 1/2 dose initially, then remaining 1/2 dose over the next 24 hours; monitor pH, serum HCO3-, and clinical status. Note: These equations provide an estimated replacement dose. The underlying cause and degree of acidosis may result in the need for larger or smaller replacement doses. In most cases, the initial goal of therapy is to target a pH of ~7.2 and a plasma bicarbonate level of ~10 mEq/L to prevent over alkalinization. According to the ARDSNet protocol, if pH remains <7.15 after ventilator adjustments, may give NaHCO3 (Brower 2004). If acid-base status is not available: 2 to 5 mEq/kg IV infusion over 4 to 8 hours; subsequent doses should be based on patient's acid-base status.	UptoDate
	Non-life-threatening: •                     2-5 mEq/kg IV infusion over 4-8 hr depending on the severity of acidosis as judged by the lowering of total CO2 content, clinical condition and pH	Medscape
	If acid-base status is available, dosages should be calculated as follows: 0.2 x weight (kg) x base deficit. Alternatively: HCO3 (mEq) required = 0.5 x weight (kg) x [24 - serum HCO3 (mEq/L)]. or Moderate metabolic acidosis: 50 to 150 mEq sodium bicarbonate diluted in 1 L of D5W to be intravenously infused at a rate of 1 to 1.5 L/hour during the first hour. If acid-base status is not available, dosages should be calculated as follows: 2 to 5 mEq/kg IV infusion over 4 to 8 hours; subsequent doses should be based on patient's acid-base status.	Drugs.com https://www.drugs.com/dosage/sodium-bicarbonate.html [Accessed 8 May 2020]
	In the treatment of chronic acidosis bicarbonate has been given orally and doses providing 57 mmol (4.8 g sodium bicarbonate) or more daily may be required. The dose of bicarbonate required for the treatment of acidotic states must be calculated on an individual basis, and is dependent on the acid–base balance and electrolyte status of the patient.	Martindale 36th Edition
	In less urgent forms of metabolic acidosis, Sodium Bicarbonate Injection, USP may be added to other intravenous fluids. The amount of bicarbonate to be given to older children and adults over a four-to eight- hour period is approximately 2 to 5 mEq/kg of body weight — depending upon the severity of the acidosis as judged by the lowering of total CO2 content, blood pH and clinical condition of the patient. Bicarbonate therapy should always be planned in a stepwise fashion since the degree of response from a given dose is not precisely predictable. Initially an infusion of 2 to 5 mEq/kg body weight over a period of 4 to 8 hours will produce a measurable improvement in the abnormal acid-base status of the blood. The next step of therapy is dependent upon the clinical response of the patient. If severe symptoms have abated, then the frequency of administration and the size of the dose may be reduced	Dailymed.nlm.nih.gov dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=2d05e1e4-0891-411d-a435-1280991fa79f&type=display
Metabolic Acidosis (severe)	Severe (except hypercarbic acidosis): •                     90-180 mEq/L (~7.5-15 g) at a rate of 1-1.5 L (first hour); adjust for further management as needed	Medscape
	Severe metabolic acidosis: 90 to 180 mEq sodium bicarbonate diluted in 1 L of D5W to be intravenously infused at a rate of 1 to 1.5 L/hour during the first hour.	Drugs.com https://www.drugs.com/dosage/sodium-bicarbonate.html [Accessed 8 May 2020]
	Sodium bicarbonate has been given intravenously by continuous infusion usually as a 1.26% (150 mmol/litre) solution or by slow intravenous injection of a stronger (hypertonic) solution of up to 8.4% (1000 mmol/litre) sodium bicarbonate.	Martindale 36th Edition
Hyperkalaemia	IV: 50 mEq over 5 minutes (as appropriate, consider methods of enhancing potassium removal/excretion)	ACLS 2010
	IV: 50 mEq over 5 minutes	Medscape
	50 mmol of sodium bicarbonate infused slowly over 5 minutes; may repeat in 30 minutes if needed. • May lower plasma K+ within 30–60 minutes and persist for several hours. • The efficacy of bicarbonate is disputed, it seems least effective in patients with advanced kidney disease; may be preferred and effective in patients with underlying metabolic acidosis.	CRITICAL CARE PHARMACY HANDBOOK, First Edition, 2013 Pharmaceutical Services Division, MOH, Malaysia
	If the patient is acidotic, give sodium bicarbonate (NaHCO3) 50–100 mmol over 1 h but be aware of the usual risks of bicarbonate administration, including fluid overload, worsening of intracellular and cerebrospinal fluid (CSF) acidosis, acute ionized hypocalcemia, and increased carbon dioxide production. Sodium bicarbonate should be used only when acidosis is severe (pH <7.1), the patient is symptomatic, or if acidosis is associated with acute hyperkalaemia. The need for bicarbonate is an indication for dialysis.	Handbook of Critical Care, Third Edition, 2009 (University of Chicago)
	Urgent treatment of hyperkalaemia  :  100 ml 8.4% sodium bicarbonate intravenously.	Handbook of Critical Care Medicine, 2009
Cardiac Arrest	IV: Initial: 1 mEq/kg/dose; repeat doses should be guided by arterial blood gases Routine use of NaHCO 3 is not recommended. May be considered in the setting of prolonged cardiac arrest only after adequate alveolar ventilation has been established and effective cardiac compressions. Note: In some cardiac arrest situations (eg, metabolic acidosis, hyperkalemia, or tricyclic antidepressant overdose), sodium bicarbonate may be beneficial.	ACLS 2010
	Initial: 1 mEq/kg/dose IV x1; base subsequent doses on results of arterial blood pH and PaCO2 as well as calculation of base deficit •                     Repeat doses may be considered in the setting of prolonged cardiac arrest only after adequate alveolar ventilation has been established	Medscape https://reference.medscape.com/drug/sodium-bicarbonate-342305 [Accessed 8 May 2020]
	A rapid intravenous dose of 200 to 300 mEq of bicarbonate, given as a 7.5% or 8.4% solution is suggested for adults. Cautions should be observed in emergencies where very rapid infusion of large quantities of bicarbonate is indicated. Bicarbonate solutions are hypertonic and may produce an undesirable rise in plasma sodium concentration in the process of correcting the metabolic acidosis. In cardiac arrest, however, the risks from acidosis exceed those of hypernatremia.	Dailymed.nlm.nih.gov dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=2d05e1e4-0891-411d-a435-1280991fa79f&type=display

PAEDIATRICS

Indication	Dosing	Reference
Metabolic Acidosis	Acute metabolic acidosis in Infants, Children, and Adolescents: Blood-gas directed dosing (equations): IV: These equations provide an estimated replacement dose. The underlying cause and degree of acidosis may result in the need for larger or smaller replacement doses. In most cases, the initial goal of therapy is to target a pH of ~7.2 to prevent overalkalinization (Androgue 2006; Furhman 2011). HCO3-(mEq) = 0.3 x weight (kg) x base deficit (mEq/L) or HCO3-(mEq) = 0.5 x weight (kg) x [24 - serum HCO3-(mEq/L)] Administer 1/2 calculated dose initially, then remaining 1/2 dose over the next 24 hours; monitor pH, serum HCO3-, and clinical status Weight-directed dosing (if acid-base status is not available): Infants, Children, and Adolescents: IV, Intraosseous: 1 to 2 mEq/kg/dose (Hegenbarth 2008), in older Children (>2 years) and Adolescents: 2 to 5 mEq/kg IV infusion over 4 to 8 hours; subsequent doses should be based on patient's acid-base status	UptoDate
	Older children: ·          2-5 mEq/kg IV infusion over 4-8 hr depending on the severity of acidosis as judged by the lowering of total CO2 content, clinical condition and pH ·          0.25-2mEq/kg IV infusion can be considered for acidosis with a pH <7.0-7.2	Medscape https://reference.medscape.com/drug/sodium-bicarbonate-342305 [Accessed 8 May 2020]
	If acid-base status is available, dosages should be calculated as follows: Infants and Children: HCO3 (mEq) required = 0.3 x weight (kg) x base deficit (mEq/L) OR HCO3 (mEq) required = 0.5 x weight (kg) x [24 - serum HCO3 (mEq/L)]. If acid-base status is not available, dosages should be calculated as follows: Older children: 2 to 5 mEq/kg IV infusion over 4 to 8 hours; subsequent doses should be based on patient acid-base status.	Drugs.com https://www.drugs.com/dosage/sodium-bicarbonate.html [Accessed 8 May 2020]
	In infants (up to two years of age), Intravenous administration at a dose not to exceed 8 mEq/kg/day is recommended. Slow administration rates and a solution diluted to 4.2% are recommended in neonates, to guard against the possibility of producing hypernatremia, decreasing cerebrospinal fluid pressure and inducing intracranial hemorrhage.	Dailymed.nlm.nih.gov dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=2d05e1e4-0891-411d-a435-1280991fa79f&type=display
Hyperkalaemia	Hyperkalaemia (adjunct) IV: 1 to 2 mEq/kg/dose has been used to redistribute extracellular potassium into cells based on physiologic understanding (Hegenbarth 2008); however, some data has shown efficacy lacking for use in acute, early treatment of hyperkalemia (ie, 60 minutes); in adult dialysis patients, while short infusions were shown to increase serum bicarbonate, they were not shown to reduce serum potassium (Ahee 2000; Blumberg 1988; Gutierrez 1991; Kim 1996; Weisberg 2008); some efficacy was observed with a long duration hypertonic bicarbonate infusion (eg, 150 mEq/L in D5W) used as rehydration fluid and/or in presence of metabolic acidosis (Weiner 1998; Weisberg 2008); serum Na should also be monitored closely	UptoDate
Cardiac Arrest	Infants, <2 years (use 4.2% solution) Initial: 1 mEq/kg/min given over 1-2 minutes IV/IO, THEN 1 mEq/kg IV q10min of arrest Not to exceed 8 mEq/kg/day ≥2  years Initial: 1 mEq/kg/dose IV x1; base subsequent doses on results of arterial blood pH and PaCO2 as well as calculation of base deficit Repeat doses may be considered in the setting of prolonged cardiac arrest only after adequate alveolar ventilation has been established	Medscape
	Infants, Children, and Adolescents: IV, Intraosseous: 1 mEq/kg/dose; repeat doses should be guided by arterial blood gases; in infants and children <2 years of age, the 4.2% (0.5 mEq/mL) solution should be used. Note: If intraosseous route is used for administration and is subsequently used to obtain blood samples for acid-base analysis, results will be inaccurate (AHA [Kleinman 2010).	PALS guidelines (under UptoDate)

Availability in Hospital Keningau:
Sodium Bicarbonate 8.4% Injection
1 mL = 1 mEq = 1 mmol

All accessed on 8 May 2020 [Prepared by Zulhelmy ; Edited by JCK Ho]