Canadian antidote guide

Sodium Bicarbonate

• NaHCO3
• Sodium hydrogen carbonate

Cardiotoxicity:

• ​The following signs and symptoms caused by sodium channel blockers, such as tricyclic antidepressants, antiarrhythmic drugs (class "Ia" or "Ic") etc. 
  • QRS widening with right ventricular delay (shown on the ECG by a prominent R wave in aVR lead and a deep S wave in lead 1; see ECG examples), and/or
  • Hypotension, and/or
  • Ventricular arrhythmia 

Blood alkalinization to reduce the distribution of salicylates in the CNS.

Urinary alkalization due to salicylate intoxication to increase elimination.

Correction of metabolic acidosis caused by methanol or ethylene glycol intoxication or secondary to toxin-associated lactic acidosis.

• Hypernatremia (50 ml NaHCO3 at 8.4% contain 1.15 g of Na), hypokalemia, fluid overload, excessive alkalinization.
• Extravasation: local ischemia, tissue necrosis, ulceration.

• Vital signs
• Serum electrolytes
• Serum calcium
• Blood gases
• Urinary pH

• Cardiotoxicity : When QRS is less than 100 milliseconds or when blood pressure is stabilized and wide-complex dysrhythmias are corrected.
• Blood alkalinization : When blood pH is 7.45 - 7.55.
• Urinary alkalinization :
  • When major clinical symptoms have resolved (except tinnitus), and;
  • the salicylates levels have decreased for two consecutive readings, and;
  • is less than 2.5 mmol/L (345.25 mg/L)
• Correction of metabolic acidosis : When blood pH is greater than 7.20.

Intravenous Route (IV)

• WARNING : Rinse tubing before and after administering sodium bicarbonate to prevent incompatibilities and the inactivation of other drugs.
• Direct IV :
  • Newborns or Infants: Not the recommended administration route.
  • Children 2 and under: Only in situations of resuscitation. Use a solution of 4.2% (0.5 mmol/ml) or dilute a solution of 8.4% (1 mmol/ml) in SWFI at a ratio of 1:1 in order to obtain a final concentration of 0.5 mmol/ml. Administer by direct IV at a maximum rate of 1 mmol/kg/min. without exceeding 10 mmol/min.
  • Children 2 and over: Only in situations of resuscitation Use a solution of 7.5% (0.89 mmol/ml) or 8.4% (1 mmol/ml). Administer by direct IV at a maximum rate of 1 mmol/kg/min. without exceeding 10 mmol/min. 
  • Adults: Use a solution of 7.5% (0.89 mmol/ml) or 8.4% (1 mmol/ml). Administer by direct IV over 1 - 2 min. at a maximum rate of 1 mmol/kg/min.
• Slow IV Infusion :
  • Administer using a volumetric pump or syringe pump.
  • Pediatric Dose: Dilute dose in a compatible solution in order to obtain a final concentration inferior or equal to 0.5 mmol/ml. Administer at a maximum rate of 1 mmol/kg/h without exceeding 50 mmol/h.
  • Adult Dose: Dilute dose in a compatible solution in order to obtain a final concentration inferior or equal to 0.5 mmol/ml. Administer over 4 - 8 hours or at a maximum rate of 50 mmol/h.
• Continuous IV Infusion: 
  • Recommended only for urinary alkalinization.
  • Administer using a volumetric pump.
  • Formula using a solution with a concentration of 7.5% (0.89 mmol/ml):
    • 134 mmol (150 ml) in 1000 ml of a compatible solution.
    • Final volume: 1150 ml.
    • Final concentration: 0.12 mmol/ml.
  • Formula using a solution with a concentration of 8.4% (1 mmol/ml):
    • 150 mmol (150 ml) in 1000 ml of a compatible solution.
    • Final volume: 1150 ml.
    • Final concentration: 0.13 mmol/ml.

Subcutaneous Route (SC)

• Do not administer by this route.

Intramuscular Route (IM)

• Do not administer by this route.

Intraosseous Route (IO)

• Possible alternative to IV route.

Compatibility

Partial list only. Consult the pharmacist on duty at your health care facility.

• Compatible solutions: D5W (preferably), D5W+¼NS, D10W, SWFI, D5W+½NS, D5W+NS, NS (choose a low-sodium solution).
  • SWFI: 500 ml and 1000 ml solutions are available from Hospira (approximately $1.50/unit). Use in cases of hypernatremia or hyperglycemia
• Y-site compatibility: aminophylline, atenolol, atropine, benztropine, codeine, digoxin, esmolol, famotidine, fentanyl, folic acid, furosemide, standard heparin, regular insulin, labetalol, lidocaine, lorazepam, magnesium (sulfate), mannitol, metoclopramide, metoprolol, milrinone, morphine, MVI, naloxone, nitroglycerin, sodium nitroprusside, octreotide, pancuronium, pentobarbital, phenobarbital, phentolamine, phenylephrine, phytonadione (vitamin K1), potassium (acetate and chloride), procainamide, propofol, propranolol, protamine, ranitidine, vasopressin.
• Y-site incompatibility: Amiodarone, atracurium, calcium (chloride and gluconate), chlorpromazine, calcium leucovorin, dantrolene, diazepam, diphenhydramine, dobutamine, dopamine, epinephrine, haloperidol, isoproterenol, ketamine, lansoprazole, meperidine, midazolam, norepinephrine, ondansetron, phenytoin, prochlorperazine, promethazine, succinylcholine, thiamin, thiopental, verapamil.
• Sodium bicarbonate inactivates catecholamines.
• Incompatible with acids, acidic salts and lactate solutions.

Stability

• Store undiluted products at room temperature (20°C - 25°C).
• Diluted with compatible solutions in PVC bag: no data. Consider maximum stability to be 24 h.
• Diluted in D5W polyolefin bag: stable for 30 h at room temperature.

• Sodium bicarbonate for injection, USP, 4.2%, Inj. Sol., 5 mmol/10ml (infants) in syringe (LifeShield or Abboject), Pfizer Canada ULC, DIN 00261971
  • Bicarbonate content (HCO3): 31 mg/ml; 0.5 mmol/ml; 0.5 mEq/ml.
  • Sodium content (na): 12 mg/ml; 0.5 mmol/ml; 0.5mEq/ml.
  • Osmolarity: 1 mOsm/ml.
• Sodium bicarbonate for injection, USP, 7.5%, Inj. Sol.,44.6 mmol/50 ml (adult)in syringe (LifeShield or Abboject), Pfizer Canada ULC , DIN 00038083 
  • Bicarbonate content (HCO3): 54 mg/ml; 0.89 mmol/ml; 0.89 mEq/ml.
  • Sodium content (Na): 21 mg/ml; 0.89 mmol/ml; 0.89 mEq/ml.
  • Osmolarity: 1.79 mOsm/ml.
• Sodium bicarbonate for injection, USP,8.4%, Inj. Sol.,10 mmol/10 ml (pediatric)or50 mmol/50 ml (adult)in syringe (LifeShield or Abboject), single-use vial of 50 mmol/50 ml, Pfizer Canada ULC , DIN 00261998 
  • Bicarbonate content (HCO3): 61 mg/ml; 1 mmol/ml; 1 mEq/ml.
  • Sodium content (Na): 23 mg/ml; 1 mmol/ml; 1 mEq/ml.
  • Osmolarity: 2 mOsm/ml.
• Sodium bicarbonate injection USP, 8,4%, Inj. Sol., 10 mmol/10ml (pediatric) or 50 mmol/50ml (adult), single-use vial of 10ml et 50ml, Omega Laboratoires LTD, DIN 02467585
  • Bicarbonate content (HCO₃) : 61 mg/ml; 1 mmol/ml; 1 mEq/ml.
  • Sodium content(Na) : 23 mg/ml; 1 mmol/ml; 1 mEq/ml.
  • Osmolarity : 2 mOsm/ml.

• At least 500 mmol.

Bruccoleri, Rebecca E., and Michele M. Burns. 2016. “A Literature Review of the Use of Sodium Bicarbonate for the Treatment of QRS Widening.” Journal of Medical Toxicology: Official Journal of the American College of Medical Toxicology 12 (1):121–29.



Lemyze, Malcolm, Juliette Masse, Charles Queva, and David Huchette. 2016. “Cardiac Effect of Sodium Bicarbonate in Sodium-Channel Blocker Poisoning.” Intensive Care Medicine 42 (4):588–90.



Lookabill, Sara K., Anna Rouse Dulaney, Greene Shepherd, and William P. Kerns. 2016. “Sodium Bicarbonate.” In Critical Care Toxicology, edited by Jeffrey Brent, Keith Burkhart, Paul Dargan, Benjamin Hatten, Bruno Megarbane, and Robert Palmer, 117:1–21. Cham: Springer International Publishing.

Proudfoot, A. T., E. P. Krenzelok, and J. A. Vale. 2004. “Position Paper on Urine Alkalinization.” Journal of Toxicology. Clinical Toxicology 42 (1):1–26.