Dose:  1 to 2 mEq/kg/dose IV (see comments)

Comments:  Bicarbonate is the most potent agent to reverse acidosis. Sodium bicarbonate functions as a physiologic buffer only in an "open system" in which CO₂ can be transported to the lungs and blown off. It has long been used in treating the underlying metabolic acidosis accompanying respiratory distress syndrome. The use of bicarbonate can be accompanied by an increase in tonicity of body fluids and the potential adverse effects on the central nervous system. In addition, if carbon dioxide is not able to escape (i.e. when the respiratory rate is fixed), as would be the case with respiratory failure, the use of sodium bicarbonate can produce a paradoxical fall in pH. The base deficit can be derived using the Siggaard-Andersen nomogram and the pH and pCO₂ obtained from ABGs to estimate the dose of sodium bicarbonate needed to correct a metabolic acidosis. Further comments on sodium bicarbonate.

Toxicity: If sodium bicarbonate is used to treat respiratory acidosis, further CO₂ retention will occur resulting in a worsening acidosis. "Vigorous" therapy with sodium bicarbonate has been associated with intraventricular hemorrhages (Simmons. NEJM 1974; 291:6).   See adverse effects associated with sodium bicarbonate.

Preparation: Sodium bicarbonate is available in 10 ml pre-filled syringe with a concentration of 0.5 mEq/ml (900 mosmol/L or 4.2%). An isotonic (1.5%) sodium bicarbonate solution can be prepared by diluting 10 ml of the concentrated injection with 18 ml of sterile water for injection. Dilution with a dextrose solution will give a higher osmolarity to the final solution. Infuse slowly. Store at room temperature. Stable for 24 hours after opening. Do not use if discolored or contains a precipitate.
 

Sodium Bicarbonate Code Sheet

Compatibility: Sodium bicarbonate is not compatible with acids, acidic salts, and many alkaloidal salts. Though there are reports of use with TPN, the acidity of the amino acids, as well as potential precipitation with calcium and magnesium salts would dictate that this combination be avoided. Not compatible with filter.   It is compatible with D2.5W, D5W, D10W, dextrose and saline solutions, dextrose and LR solutions, LR, 0.45% NS, and normal saline. Sodium bicarbonate also has at least "Y"-site compatibility with acyclovir, amikacin, aminophylline, amphotericin, atropine, aztreonam, ceftazidime, cephalothin, chloramphenicol, clindamycin, dexamethasone, erythromycin, esmolol, famotidine, fentanyl, filgrastim, furosemide, heparin, hydrocortisone, indomethacin, insulin, kanamycin, nafcillin,   phytonadione, phenytoin, piperacillin-tazobactam, potassium chloride, propofol, tolazoline, and vancomycin. Incompatible with allopurinol, amiodarone, amrinone, calcium gluconate, cefotaxime, dobutamine, dopamine, epinephrine, glycopyrrolate, imipenem-cilastatin, isoproterenol, labetalol, magnesium sulfate, methadone, metoclopramide, midazolam, oxacillin, penicillin G (potassium), phenobarbital, procaine HCl, and ticarcillin-clavulanate .  It has equivocal compatibility with ampicillin, bupivacaine, lidocaine, methicillin, morphine, and vancomycin.