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treatment_sodium_bicarbonate [2025/04/13 01:10] – [2.1 QRS Widening Secondary to Fast Sodium Channel Blockade] jkohtstreatment_sodium_bicarbonate [2025/04/16 04:26] (current) – [2.2 Salicylate Toxicity] jkohts
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 ===== - Overview ===== ===== - Overview =====
 +Sodium bicarbonate (NaHCO₃) is primarily used in toxicology to treat sodium channel blocker toxicity (e.g. TCA toxicity). 
  
- +The patient should then be [[concept_serum_alkalinization|hyperventilated]].
-Sodium Bicarbonate (NaHCO3) is the primary antidote for [[:wikitox:2.1.11.9.2.1_tricyclic_antidepressants|TCA]] poisoning. As these are, by far, the most common cause of cardiac arrest in out of hospital poisonings - patients with drug overdose presenting in cardiac arrest or arresting shortly after arrival should receive a bolus of 1 ampoule of NaHCO<sub>3</sub>. +
- +
-The patient should then be [[:wikitox:alkalinisation|hyperventilated]].+
  
  
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   * Also see: Tricyclic antidepressants, bupropion, propranolol, flecainide, local anesthetic agents.   * Also see: Tricyclic antidepressants, bupropion, propranolol, flecainide, local anesthetic agents.
   * **Adult:**   * **Adult:**
-    * 💊 **Sodium Bicarbonate 1-2 mmol/kg IV** (i.e. 1-2 mL/kg of 8.4% NaHCO3), q2min.+    * 💊 **Sodium bicarbonate 1-2 mmol/kg IV** (i.e. 1-2 mL/kg of 8.4% NaHCO3), q2min.
   * **Child:**   * **Child:**
-    * 💊👶 **Sodium Bicarbonate 1-2 mmol/kg IV** (i.e. 1-2 mL/kg of 8.4% NaHCO3), q2min.+    * 💊👶 **Sodium bicarbonate 1-2 mmol/kg IV** (i.e. 1-2 mL/kg of 8.4% NaHCO3), q2min.
   * Repeat boluses until signs of cardiotoxicity (QRS widening, wide complex dysrhythmias) improve.   * Repeat boluses until signs of cardiotoxicity (QRS widening, wide complex dysrhythmias) improve.
   * Do not exceed serum pH 7.55, Na⁺ 155 mmol/L.   * Do not exceed serum pH 7.55, Na⁺ 155 mmol/L.
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   * Alkalinization therapy in salicylate toxicity works by ↓ CNS redistribution of salicylates (alters drug distribution), and enhances urinary elimination (ion trapping).   * Alkalinization therapy in salicylate toxicity works by ↓ CNS redistribution of salicylates (alters drug distribution), and enhances urinary elimination (ion trapping).
   * **Adult:**   * **Adult:**
-    * 💊 **Sodium Bicarbonate 1-2 mmol/kg IV** (i.e. 1-2 mL/kg of 8.4% NaHCO3), as initial dose, then start infusion. +    * 💊 **Sodium bicarbonate 1-2 mmol/kg IV** (i.e. 1-2 mL/kg of 8.4% NaHCO3), as initial dose, then start infusion. 
-    * 💊 **Sodium Bicarbonate 25 mmol/hr IV infusion**. +    * 💊 **Sodium bicarbonate 25 mmol/hr IV infusion**. 
-      * e.g. 150 mmol of Sodium Bicarbonate in 850 mL 5% dextrose, at 250 mL/hr.+      * e.g. 150 mmol of Sodium bicarbonate in 850 mL 5% dextrose, at 250 mL/hr.
   * **Child:**   * **Child:**
-    * 💊👶 **Sodium Bicarbonate 1-2 mmol/kg IV** (i.e. 1-2 mL/kg of 8.4% NaHCO3), as initial dose, then start infusion. +    * 💊👶 **Sodium bicarbonate 1-2 mmol/kg IV** (i.e. 1-2 mL/kg of 8.4% NaHCO3), as initial dose, then start infusion. 
-    * 💊👶 **Sodium Bicarbonate 1.5-2× patient's hourly maintenance fluid requirement (weight-based) IV infusion**, then titrate to goal pH. +    * 💊👶 **Sodium bicarbonate 1.5-2× patient's hourly maintenance fluid requirement (weight-based) IV infusion**, then titrate to goal pH.
-  * Maintain normokalemia.+
   * Goals:   * Goals:
     * Serum pH 7.5-7.55.     * Serum pH 7.5-7.55.
     * Urinary pH >7.5.     * Urinary pH >7.5.
     * Urine output 2-3 mL/kg/hr.     * Urine output 2-3 mL/kg/hr.
 +    * Maintain normokalemia.
  
  
  
-==== - Indication 3 ==== 
  
-  * Also see: [[relevant pages]]. +===== - Cautions & Contraindications =====
-  * **Adult:** 💊 **DrugName Dose Route**, Frequency. +
-  * **Child:** 💊👶 **DrugName Dose Route**, Frequency. +
-  * Other notes if applicable.+
  
 +  * Metabolic or respiratory alkalosis - do not exceed pH 7.55.
 +  * Severe hypernatremia - do not exceed Na⁺ 155 mmol/L.
 +  * Hypokalemia.
 +  * Acute pulmonary edema.
  
-===== - Cautions & Contraindications ===== 
  
-  * Metabolic or respiratory alkalosis 
-  * Severe hypernatremia 
-  * Hypokalemia 
-  * Acute pulmonary edema 
 ===== - Special Populations ===== ===== - Special Populations =====
-**Pregnancy rating:** 
  
-**Lactation:**+**Renal impairment:** Use with caution in patients with severe renal impairment due to the risk of fluid overload and hypernatremia.
  
-**Renal impairment:** 
  
-**Hepatic impairment:**+===== - Adverse Effects ===== 
 +  * **Renal:** fluid overload, acute pulmonary edema. 
 +  * **Metabolic:** metabolic alkalosis, hypernatremia, hypokalemia, hyperosmolarity. 
 +  * **Skin:** local phlebitis, cellulitis, extravasation injury.
  
- 
-===== - Adverse Effects ===== 
-  * Description of important/serious adverse effects, e.g. 
-  * Serotonin syndrome:  
-  * Systems e.g.  
-  * **GI:** 
-  * **Resp:** 
-  * **MSK:** local phlebitis 
-  * Frequency e.g. 
-  * **Common:** 
  
  
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 ==== - Pharmacodynamics ==== ==== - Pharmacodynamics ====
-**Mechanism of action:**+**Mechanism of action:** Hypertonic sodium bicarbonate (e.g. 8.4%) ameliorates toxicity by multiple mechanisms, including ↑ extracellular sodium concentration, ↑ plasma bicarbonate concentration, ↑ serum pH, and ↑ urinary pH.  
  
 ==== - Pharmacokinetics ==== ==== - Pharmacokinetics ====
 +The pharmacokinetics of sodium bicarbonate are challenging to measure, as the bicarbonate component rapidly buffers H⁺ ions and is converted into CO₂.
  
 **Absorption:** **Absorption:**
-  * Oral bioavailability: +  * Oral bioavailability: good oral bioavailability if ingested.
-  * GI tract absorption: +
-  * First pass metabolism:+
  
 **Distribution:** **Distribution:**
-  * Vd: +  * Vd: 0.2-0.4 L/kg.
-  * Lipid solubility: +
-    * Crosses/Does not cross BBB +
-    * Crosses/Does not cross placenta +
-    * Excreted/Not excreted in breast milk +
-  * Protein binding: +
-  * Tmax:+
  
 **Metabolism:** **Metabolism:**
 +  * Reacts with H⁺ to form H₂O and CO₂.
 +  * Bicarbonate contributes to 80% of extracellular buffering capacity.
  
 **Excretion:** **Excretion:**
-  * Elimination t½: +  * CO₂ is exhaled. 
-  * Hepatic clearance: +  * Bicarbonate and Na⁺ is excreted renally. 
-  * Renal clearance:+
  
 ==== - Pharmaceutics ==== ==== - Pharmaceutics ====
-**Formulation:**+**Formulation:**  Sodium bicarbonate 8.4% vials/ampoules contain 1 mmol/mL of sodium bicarbonate solution.