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Sodium Bicarbonate

Pronunciation

Class: Alkalinizing Agents
CAS Number: 144-55-8
Brands: Baking Soda, Neut, Soda Mint

Introduction

Alkalinizing agent.100 a

Uses for Sodium Bicarbonate

Acidosis

Treatment of metabolic acidosis associated with many conditions including severe renal disease (e.g., renal tubular acidosis), uncontrolled diabetes (ketoacidosis), extracorporeal circulation of the blood, cardiac arrest, circulatory insufficiency caused by shock or severe dehydration, ureterosigmoidostomy, lactic acidosis, alcoholic ketoacidosis, use of carbonic anhydrase inhibitors, and ammonium chloride administration.a

Generally considered the alkalinizing agent of choice for oral or parenteral therapy.a

Diabetic Ketoacidosis

Specific role of sodium bicarbonate therapy in the treatment of diabetic ketoacidosis not established.a Administration is generally reserved for the treatment of severe acidosis (e.g., arterial pH less than 7–7.15 or serum bicarbonate concentration of 8 mEq/L or less) because of the potential risks of sodium bicarbonate therapy in the treatment of this disorder.b

Advanced Cardiovascular Life Support

ACLS guidelines state that IV sodium bicarbonate is not recommended for routine use during cardiac arrest; limited data to support such use and potentially associated with detrimental effects.400 401 However, may be useful in some resuscitation situations (e.g., preexisting metabolic acidosis, hyperkalemia, tricyclic antidepressant overdosage).401

Alkalinization of Urine

Treatment of hemolytic reactions requiring alkalinization of the urine to diminish the nephrotoxic effects of blood pigments; also to increase urinary pH in order to increase the solubility of certain weak acids (e.g., cystine, sulfonamides, uric acid).a

Sodium Bicarbonate Dosage and Administration

General

  • Dosage is determined by severity of the acidosis, appropriate laboratory determinations, and the patient’s age, weight, and clinical condition.a Frequent laboratory determinations and clinical evaluation of the patient are essential during therapy, especially during prolonged therapy, to monitor changes in fluid and electrolyte and acid-base balance.a

  • Full correction of bicarbonate deficit should not be attempted during the first 24 hours of sodium bicarbonate therapy, since this may result in precipitation of metabolic alkalosis because of delayed physiologic compensatory mechanisms.a

  • Fluid and electrolyte balance of the patient must be carefully monitored during therapy with the drug because of the sodium content of sodium bicarbonate.a

Administration

Administer orally, by direct IV injection or infusion.a

May be administered by intraosseous (IO) injection in the setting of pediatric advanced life support (PALS).403

Also has been administered by sub-Q injection if diluted to isotonicity (1.5% sodium bicarbonate solution); avoid extravasation of hypertonic sodium bicarbonate injections.a

Oral Administration

Administered orally in the treatment of mild to moderately severe acidosis, in conditions (e.g., chronic renal failure) requiring prolonged therapy with an alkalinizing agent, and in conditions in which IV administration of the drug is not necessary (e.g., alkalinization of the urine).

IV Administration

For solution and drug compatibility information, see Compatibility under Stability.

Rate of Administration

Neonates and children <2 years of age: Administer hypertonic sodium bicarbonate injections by slow IV infusion of a 4.2% solution (up to 8 mEq/kg daily).a

Dosage

Each 84 mg or 1 g of sodium bicarbonate contains 1 or about 12 mEq, respectively, each of sodium and bicarbonate ions.a

Pediatric Patients

Metabolic Acidosis
IV

Older children: 2–5 mEq/kg as an infusion over 4–8 hours in less urgent forms of metabolic acidosis.a Subsequent doses should be determined by the response of the patient and appropriate laboratory determinations.a

Plan sodium bicarbonate therapy in a stepwise manner, since the degree of response following a given dose is not always predictable.a Reduce dose and frequency of administration after severe symptoms have improved.a

Pediatric Resuscitation
IV/IO

Infants and children: Some experts recommend 1 mEq/kg administered slowly.403

Ventricular arrhythmias associated with cocaine toxicity: Some experts recommended 1–2 mEq/kg.402 403

Alkalinization of Urine
Oral

1–10 mEq (84–840 mg) per kg daily, adjusted according to response.a

Adults

Metabolic Acidosis
IV

Initially, administer no more than 33–50% of the calculated bicarbonate requirements when initial, rapid administration of the drug is considered necessary.a Consult specialized references on fluid and electrolyte and acid-base balance for specific recommendations.a

2–5 mEq/kg dose as an infusion over 4–8 hours in less urgent forms of metabolic acidosis.a Subsequent doses should be determined by the response of the patient and appropriate laboratory determinations.a Therapy should be planned in a stepwise manner, since the degree of response following a given dose is not always predictable.a Generally, the dose and frequency of administration should be reduced after severe symptoms have improved.a

Diabetic Ketoacidosis
IV

Partially correct acidosis, generally to an arterial pH of about 7.2, in order to avoid rebound alkalosis.a

ACLS
IV

If used in certain resuscitation situations (e.g., preexisting metabolic acidosis, hyperkalemia, tricyclic antidepressant overdosage), usual initial dose is 1 mEq/kg.401 Whenever possible, dosage should be guided by bicarbonate concentration or by calculated base deficit obtained from blood gas analysis or laboratory measurement.401 Complete correction of the base deficit not recommended to minimize risk of alkalosis.401

For management of cardiac arrest due to hyperkalemia, 50 mEq has been administered IV over 5 minutes as adjunctive therapy to other standard ACLS measures.196

Acidosis Associated with Chronic Renal Failure
Oral

Initially, 20–36 mEq daily, given in divided doses when plasma bicarbonate concentration is less than 15 mEq/L.a Titrate dosage to provide a plasma bicarbonate concentration of about 18–20 mEq/L.a To relieve symptoms and prevent or stabilize renal failure and osteomalacia in patients with renal tubular acidosis, higher dosages of sodium bicarbonate are necessary.a

Distal (type 1) renal tubular acidosis: Initially, 0.5–2 mEq/kg daily, given in 4 or 5 divided doses.a Titrate dosage until hypercalciuria and acidosis are controlled, and according to the response and tolerance of the patient.a Alternatively, 48–72 mEq (about 4–6 g) daily.a

Proximal (type 2) renal tubular acidosis: 4–10 mEq/kg daily, given in divided doses.a

Alkalinization of Urine
Oral

Initially, 48 mEq (4 g), followed by 12–24 mEq (1–2 g) every 4 hours.a Dosages of 30–48 mEq (2.5–4 g) every 4 hours, up to 192 mEq (16 g) daily, may be required in some patients.a Titrate dosage to maintain the desired urinary pH.a

Cautions for Sodium Bicarbonate

Contraindications

  • Metabolic or respiratory alkalosis.a

  • Hypocalcemia in which alkalosis may induce tetany.a

  • Excessive chloride loss from vomiting or continuous GI suctioning.a

  • Risk of developing diuretic-induced hypochloremic alkalosis.a

  • Oral administration as an antidote in the treatment of acute ingestion of strong mineral acids, since formation of carbon dioxide gas during neutralization may cause gastric distention and possible rupture.a

Warnings/Precautions

Warnings

CHF

Use with extreme caution in patients with CHF.a

Fluid and/or Solute Overload

Possible fluid and/or solute overload following IV administration resulting in dilution of serum electrolytes, overhydration, congestive conditions, or pulmonary edema.a Risk of dilutional conditions is inversely proportional to the electrolyte concentration administered.a Risk of solute overload and resultant congestive conditions with peripheral and/or pulmonary edema is directly proportional to the electrolyte concentration administered.a

Major Toxicities

Electrolyte Disturbances

Potassium depletion may predispose to metabolic alkalosis and coexistent hypocalcemia may result in tetany and carpopedal spasm as the plasma pH increases.a Correct electrolyte disturbances prior to or concomitantly with administration of sodium bicarbonate therapy to minimize the risks of preexisting hypokalemia and/or hypocalcemia.a

General Precautions

Dosing Considerations

Generally, the goal of alkalinizing therapy is to correct the acid-base disturbance while avoiding overdosage and resultant metabolic alkalosis.a Frequent laboratory determinations and clinical evaluation of the patient are essential to monitor changes in fluid and electrolyte and acid-base balance.a

Extravasation

Chemical cellulitis with inadvertent extravasation of hypertonic solutions, subsequently resulting in tissue necrosis, ulceration, and/or sloughing at the site of injection.a Treat extravasation by elevating the affected area, applying warm compresses to the site, and locally injecting lidocaine or hyaluronidase.a

Specific Populations

Pregnancy

Category C.b

Pediatric Use

Neonates and children < 2 years of age: Rapid injection (10 mL/minute) of hypertonic sodium bicarbonate solutions may produce hypernatremia, decreased CSF pressure, and possible intracranial hemorrhage.a

Renal Impairment

Use with extreme caution in patients with renal insufficiency, especially those with severe insufficiency such as oliguria or anuria.a

When given in large doses or to patients with renal insufficiency, may cause metabolic alkalosis.100 401 Metabolic alkalosis may be accompanied by hyperirritability or tetany.a

Common Adverse Effects

Gastric distention and flatulence with oral administration.a

Interactions for Sodium Bicarbonate

Specific Drugs

Drug

Interaction

Comments

Corticosteroids

Possible sodium retention with resulting edemaa

Use with extreme cautiona

Corticotropin

Possible sodium retention with resulting edemaa

Use with extreme cautiona

Stability

Storage

Oral

Tablets

Tight containers at 15–30°C.a

Parenteral

Injection

15–30°C.a Avoid freezing and extreme heat.b

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Parenteral

Solution CompatibilityHID

Compatible

Dextrose–Ringer’s injection combinations

Dextrose–Ringer’s injection, lactated, combinations

Dextrose–saline combinations

Dextrose 5% in sodium chloride 0.9%

Dextrose 2.5, 5, or 10% in water

Ionosol products

Ringer's injection

Sodium chloride 0.45 or 0.9%

Sodium lactate (1/6) M

Incompatible

Dextrose 5% in Ringer’s injection, lactated

Variable

Fat emulsion 10%, IV

Ringer’s injection, lactated

Drug Compatibility
Admixture CompatibilityHID

Compatible

Amikacin sulfate

Aminophylline

Amphotericin B

Atropine sulfate

Cefoxitin sodium

Ceftazidime

Ceftriaxone sodium

Chloramphenicol sodium succinate

Clindamycin phosphate

Cytarabine

Erythromycin lactobionate

Esmolol HCl

Furosemide

Heparin sodium

Hyaluronidase

Lidocaine HCl

Mannitol

Meperidine HCl

Methotrexate sodium

Methyldopate HCl

Multivitamins

Nafcillin sodium

Oxytocin

Phenylephrine HCl

Phytonadione

Potassium chloride

Prochlorperazine edisylate

Verapamil HCl

Incompatible

Ampicillin sodium

Ascorbic acid injection

Carboplatin

Carmustine

Ciprofloxacin

Cisplatin

Dobutamine HCl

Dopamine HCl

Epinephrine HCl

Ertapenem sodium

Imipenem–cilastatin sodium

Isoproterenol HCl

Labetalol HCl

Meropenem

Nicardipine HCl

Norepinephrine bitartrate

Pentazocine lactate

Pentobarbital sodium

Succinylcholine chloride

Voriconazole

Variable

Calcium chloride

Calcium gluconate

Levofloxacin

Magnesium sulfate

MIdazolam HCl

Penicillin G potassium

Y-Site CompatibilityHID

Compatible

Acyclovir sodium

Amifostine

Asparaginase

Aztreonam

Bivalirudin

Ceftaroline fosamil

Ceftriaxone sodium

Cladribine

Cyclophosphamide

Cytarabine

Daunorubicin HCl

Dexamethasone sodium phosphate

Dexmedetomidine HCl

Docetaxel

Doripenem

Doxorubicin HCl

Etoposide

Etoposide phosphate

Famotidine

Filgrastim

Fludarabine phosphate

Gallium nitrate

Gemcitabine HCl

Granisetron HCl

Heparin

Heparin sodium with hydrocortisone sodium succinate

Hydroxyethyl starch 130/0.4 in sodium chloride 0.9%

Ifosfamide

Indomethacin sodium trihydrate

Insulin, regular

Levofloxacin

Linezolid

Melphalan HCl

Mesna

Methylprednisolone sodium succinate

Milrinone lactate

Morphine sulfate

Paclitaxel

Pemetrexed disodium

Piperacillin sodium–tazobactam sodium

Potassium chloride

Propofol

Remifentanil HCl

Tacrolimus

Telavancin HCl

Teniposide

Thiotepa

Vancomycin HCl

Vasopressin

Incompatible

Allopurinol sodium

Amiodarone HCl

Amphotericin B cholesteryl sulfate complex

Anidulafungin

Calcium chloride

Doxorubicin HCl liposome injection

Fenoldopam mesylate

Hetastarch in lactated electrolyte injection (Hextend)

Idarubicin HCl

Imipenem–cilastatin sodium

Leucovorin calcium

Midazolam HCl

Nalbuphine HCl

Ondansetron HCl

Oxacillin sodium

Sargramostim

Verapamil HCl

Vincristine sulfate

Vinorelbine tartrate

Variable

Ciprofloxacin

Cisatracurium besylate

Diltiazem HCl

Actions

  • Dissociates to provide bicarbonate ion; bicarbonate is the conjugate base component of the principal extracellular buffer in the body, the bicarbonate:carbonic acid buffer.a Changes in the concentration of either component of the buffer can cause a decrease or increase in pH.a

  • Administration of sodium bicarbonate, by decreasing pH, can cause a redistribution of potassium ions into cells in patients with acidosis.a

  • Provides bicarbonate, which is readily excreted in urine; administration of the drug will increase urinary pH in patients with normal renal function.a Alkalinizing the urine can increase the solubility of certain weak acids (e.g., cystine, uric acid) and can increase the ionization and urinary excretion of lipid-soluble organic acids (e.g., phenobarbital, salicylates) that are reabsorbed in the kidney via diffusion of the un-ionized species.a

  • Potent antacid action; each gram of sodium bicarbonate has an in vitro neutralizing capacity of about 12 mEq of acid.a

Advice to Patients

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs as well as any concomitant illnesses.b

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.b

  • Importance of informing patients of other important precautionary information. (See Cautions.)b

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Sodium Bicarbonate

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Powder*

Arm & Hammer Baking Soda

Church & Dwight

Tablets

325 mg*

Soda Mint

CMC

Sodium Bicarbonate Tablets

650 mg*

Parenteral

Injection

4.2% (0.5 mEq/mL) (2.5 or 5 mEq)*

Sodium Bicarbonate Injection

5% (0.595 mEq/mL) (297.5 mEq)*

Sodium Bicarbonate Injection

7.5% (0.892 mEq/mL) (8.92 or 44.6 mEq)*

Sodium Bicarbonate Injection

8.4% (1 mEq/mL) (10 or 50 mEq)*

Sodium Bicarbonate Injection

Injection, for preparation of IV admixtures

7.5% (0.892 mEq/mL) (178.4 mEq) pharmacy bulk package

Sodium Bicarbonate Injection MaxiVial

American Pharmaceutical Partners

Solution, sterile, to adjust pH of injections

4% (0.48 mEq/mL) (2.4 mEq)

Neut

Hospira

4.2% (0.5 mEq/mL) (2.5 mEq)

Sodium Bicarbonate Additive Solution

AHFS DI Essentials. © Copyright 2017, Selected Revisions January 23, 2017. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

Only references cited for selected revisions after 1984 are available electronically.

100. Hospira, Inc. Sodium bicarbonate injection prescribing information. Lake Forest, IL; 2005.

196. Vanden Hoek TL, Morrison LJ, Shuster M et al. Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 122(18 Suppl 3):S829-61.

400. Link MS, Berkow LC, Kudenchuk PJ et al. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(18 Suppl 2):S444-64.

401. Neumar RW, Otto CW, Link MS et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 122(18 Suppl 3):S729-67.

402. de Caen AR, Berg MD, Chameides L et al. Part 12: Pediatric Advanced Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(18 Suppl 2):S526-42. [PubMed 26473000]

403. Kleinman ME, Chameides L, Schexnayder SM et al. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 122(18 Suppl 3):S876-908.

HID. Trissel LA. Handbook on injectable drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013:1030-40.

a. AHFS drug information 2017. McEvoy GK, ed. Sodium bicarbonate. Bethesda, MD: American Society of Health-System Pharmacists; 2017.

b. Abott Laboratories. Sodium Bicarbonate injection, prescribing information. North Chicago, IL; 1979 Dec.

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