Sodium Bicarbonate

NaHCO3

Antidote

Pediatric

Sodium Bicarbonate

NaHCO3

Indications

Drug or toxin-induced wide complex dysrhythmias: (e.g. tricyclic antidepressants).
Toxin-induced metabolic acidosis (e.g. methanol, ethylene glycol, salicylate, metformin).
Alkalinization of the urine to enhance drug elimination (e.g. salicylate, chlorphenoxy herbicides, phenobarbital, methotrexate) or to prevent nephrotoxicity from rhabdomyolysis.
Adjunctive therapy for chlorine gas inhalation with respiratory symptoms.

Dosage

Caution with rapid infusion of hypertonic solutions in neonates and small children: hypernatremia and hyperosmolality may occur. Titrate carefully to achieve plasma or urine pH goals. Note: 8.4 % Sodium Bicarbonate = 1 mmol/mL or 1 mEq/mL and and 4.2 % Sodium Bicarbonate = 0.5 mmol/mL or 0.5 mEq/mL

Drug or toxin-induced wide complex dysrrhythmias:

Neonates and children less than 2 years: 1 mmol/kg IV direct over 1 - 2 minutes [use 2 mL/kg of 0.5 mmol/mL (4.2%) solution to decrease osmotic load].
Children greater than 2 years: 1 mmol/kg IV direct over 1 - 2 minutes.
-Repeat bolus as required to improve signs of cardiac toxicity (QRS greater than 100 ms, hypotension, wide complex dysrrhythmias). Do not exceed a serum pH of 7.55.
Toxin-induced metabolic acidosis: 0.5 - 1 mmol/kg IV direct. Repeat as required to maintain serum pH greater than 7.20.
Urine alkalinization: Infuse a 0.15 mmol/mL sodium bicarbonate solution at 2 - 3 mL/kg/hour. Goal is a urine pH of greater than 7.5. Correction of hypokalemia is required to achieve alkaline diuresis.

Chlorine gas-induced inhalational injury: 4 mL of a 4.2% sodium bicarbonate solution by nebulizer. One dose is often adequate; repeat doses may be necessary in more severe cases. Contact the Poison Centre for guidance.

Administration

IV Direct: Rapid injection of greater than 10 mL/minute of hypertonic sodium bicarbonate in neonates and children under 2 years old may produce hypernatremia, decreased cerebral spinal fluid pressure and may result in intracranial hemorrhage.

Neonates and children less than 2 years:
-0.5 mmol/mL (4.2%) solution undiluted or to prepare a 0.5 mmol/mL solution dilute 1 mmol/mL (8.4%) solution 1:1 in sterile water.
- Neonates and infants: Maximum rate: 10 mmol/minute.
- Children greater than or equal to 2 years: 1 mmol/mL (8.4%) solution undiluted.
- Blood pressure monitoring, blood gas (acid-base) monitoring, serum electrolyte monitoring and respiratory support are required.

Infusion: For a final concentration of 0.15 mmol/mL: add 150 mmol (150 mL of mmol/mL (8.4%) sodium bicarbonate) to 850 mL of dextrose 5% in water. May administer up to 0.5 mmol/mL solution in peripheral line.
Blood gases (acid-base balance) and serum electrolytes must be monitored.
Nebulization: For a final concentration of 4.2%: add 2 mL of 8.4% sodium bicarbonate solution to 2 mL of sterile water.

Compatibility, Stability

Compatible with sodium chloride 0.9% and dextrose 5% in water.

Potential Hazards of Administration

Phlebitis (especially with direct administration).
Alkalosis, hypernatremia, edema (especially patients with cardiac, renal, and hepatic insufficiency), hypokalemia, hyperosmolality.
Hypocalcemia, tetany, neuromuscular hyperactivity.

Miscellaneous

8.4% solution contains 1 mmol/mL of sodium bicarbonate. Each 84 mg of sodium bicarbonate provides 1 mmol (1 mEq) of sodium and bicarbonate ions.
4.2% sodium bicarbonate = 0.5 mmol/mL.

References…

Bailey, B., Blais, R., Gaudreault, P., Gosselin, S., & Laliberte, M. (2009). Antidotes en toxicologie d'urgence (3rd ed.). Quebec, Canada: Centre antipoison du Quebec.

D'Alessandro, L. C., Rieder, M. J., Gloor, J., Freeman, D., & Buffo-Sequiera, I. (2009). Life-threatening flecainide intoxication in a young child secondary to medication error. The Annals of Pharmacotherapy, 43, 1522-1527.

Goldfrank, L. R., Nelson, L. S., Lewin, N. A., Howland, M. A., Hoffman, R. S., (2015). Goldfrank's toxicologic emergencies(Tenth ed.). New York: McGraw Hill.

IWK Regional Poison Centre. (2013). Sodium channel blockers (wide QRS): A brief overview for emergency departments. Unpublished manuscript.

IWK Regional Poison Centre. (2013). Salicylate (ASA) toxicity: A brief overview for emergency departments. Unpublished manuscript.

Micromedex, T. H. A. (2014). Micromedex health care systems. Retrieved from http://www.micromedexsolutions.com

Neavyn, M. J., Boyer, E. W., Bird, S. B., & Babu, K. M. (2013). Sodium acetate as a replacement for sodium bicarbonate in medical toxicolgy: A review. Journal of Medical Toxicology, 9, 250-254.

Olson, K. R. (2007). Poisoning & drug overdose (Sixth ed.). New York: McGraw Hill.

Phelps SJ, C. C. (2013). Teddy bear, pediatric injectable drugs. Retrieved from http://www.pharmpress.com/product/MC_PED/pediatric-injectable-drugs

Shannon, M. W., Borron, S. W., & Burns, M. J. (2007). Haddad and Winchester's clinical management of poisoning and drug overdose (Fourth ed.). Philadelphia: Saunders Elsevier.

Trissel, Lawrence, A,. (2013). Handbook on injectable drugs (17th ed.). Bethesda, Maryland: American Society of Health-System Pharmacists

Vajner 111, J. E., & Lung, D. (2013). Case files of the university of California San Francisco medical toxicology fellowship: Acute chlorine gas inhalation and the utility of nebulized sodium bicarbonate. Journal of Medical Toxicology, 9, 259-265.