Sodium Bicarbonate Revisited

by the renowned pediatrician, Dr Satish Deopujari,
National Chairperson (Ex)
Intensive Care Chapter I A P
Founder Chairman.....
National conference on pediatric critical care
Professor of pediatrics ( Hon ) JNMC:Wardha
Nagpur : INDIA

1. Sodium Bicarbonate Revisited

Sodium Bicarbonate Revisited

2. Acidosis is thought to have adverse physiological effects and
generally is associated with increased mortality. Consequently,
therapy to correct acidosis, usually with sodium bicarbonate is
been widely used.

In recent years, however, this approach is changing.
Disease process
Add acid
Loose alkali
acidosis Impaired acid excretion
More than 100 years of Soda Bi Carbonate

3. Adverse Effects Of
Acidosis ……………….

 Depressed myocardial contractility
 Decreased catecholamine efficacy
 Arrhythmias
 Pulmonary vasoconstriction

 Glycolytic enzyme
phosphofructokinase
is pH dependent resulting in the
impaired utilization of glucose

Below 7.o

4. Sodium Bicarbonate

 Hypertonicity and hyperosmolality
 Hypercapnia and intracellular acidosis
 Ionized hypocalcaemia
 Decreased oxygen delivery
 Hypokalemia
 Increased organic acid production

 Rebound alkalosis
 Decreased VF threshold , arrhythmias
 Repeated doses : transient hypotension
 Intracellular acidosis / CSF acidosis
 Catecholamine inactivation
 Precipitation ( cal. carbonate )
 Local infiltration necrosis

5. Hypertonicity and hyperosmolality
7.5 % sodium bicarbonate
Sodium 0.9 mEq / ml
Osmolality : 1700 mOsm /lit.
Normal serum osmolality is around 290
1700 / 6 = 284 , that’s why ideal
dilution of S.B. should be 6 times and
with 5 % dextrose

6. NaHCO
3 Na + HCO
3
H HCO
3
H
2O + CO
2
Intracellular
acidosis

7. 60 mmHg
90 %
7.4
7.8
7.0
Impaired tissue oxygenation with
correction of acidemia .
Hb.
Sat.%
RT.
LT.

8. Oxygen delivery

24 to 48 hrs
Low 2-3 DPG levels
Secondary to reduced glycolysis
Direct effect of
pH
on hemoglobin
reducing
affinity of oxygen
acute acidemia facilitates oxygen delivery, whereas
more chronic acidemia hampers oxygen delivery.
Correcting acute acidemia could be more dangerous

9. Sodium Bicarbonate

Hypertonicity and hyperosmolality
Hypercapnia and intracellular acidosis
Ionized hypocalcaemia
Decreased oxygen delivery
Hypokalemia
Rebound alkalosis
Decreased VF threshold , arrhythmias
Increased lactate production
Repeated doses : transient hypotension
Intracellular acidosis / CSF acidosis
Catecholamine inactivation
Precipitation ( cal carbonate )
Local infiltration necrosis

10. Case 1…………………
8 months old child with diarrhea and LRI is in shock
His ABG is
pH 7.01
Pco
2 36
HCO
3 5.5
ACIDOSIS
LOW BICARB
BUT CO
2
IS HIGH ?
WOULD BICARB BE INDICATED ?
NO

11. Case 2.
Preterm weighing 1.8 kg was on oral feeds and
developed Diarrhea , junior resident noted that the
baby was moderately Dehydrated and had
respiratory rate of 58 / min.
Bolus of normal saline was given followed by a dose
of bicarb , thinking that the baby may be acidotic.
After about 4 hours baby had seizures .
Sugar normal and so was calcium , seizure were
controlled but recurred Again ……………….
Though the serum calcium was “normal ”
These were hypocalcaemic seizures .
Ionic calcium low

12. CASE 3………….
DKA WITH RT LOWER LOBE CONSOLIDATION AND HYPOXIA
Ph 7.016
CO
2 6
BICARB 6
PO
2 58
Severe metabolic acidosis with mild hypoxia
Sugar 689 , ketones ++++ , COMA
Received bicarb with other standard protocol for
DKA……………sugar 326 mg %
Ph 7.36
CO
2 34
BICARB 18
PO
2 63
ABG LOOKS BETTER ,
MILD HYPOTENSION , ON SUPPORT
SUGAR IS OK
Patient deteriorates soon for no obvious
reason , his sugar is OK , ABG = Acidosis
Anion gap still wide , ketones not very high
Ph 7.16
CO
2 14
BICARB 9
PO
2 57
8 HOURS AFTER
LACTIC ACIDOSIS

13. Rapid correction of acidosis shifts curve
to left……..tissue hypoxia
Mild hypotension
Diabetics have low 2.3. DPG
Soda bicarb. promotes lactic acidosis
In severe DKA, bicarb therapy is not
supported by the literature. In fact, at
least 2 human studies have shown possible
deleterious effects of bicarbonate
administration even in patients with serum
pH less than 7.0 . Thus the administration
of sodium bicarbonate to patients with
diabetic ketoacidosis cannot be
recommended at any pH ( class 1 )

14. •Giving bicarbonate to a patient with a true
bicarbonate deficit is not controversial

•Controversy arises when the decrease in
bicarbonate concentration is the result of its
conversion to another base which, given time,
can be converted back to bicarbonate

15. What are the deleterious effects of acidemia ?
Is acidemia severe enough to warrant therapy ?
How much bicarbonate ?
what are deleterious effects of Bicarbonates ?


In considering acute
bicarbonate replacement four
questions should be thought of

16.  SEVERE METABOLIC ACIDOSIS WITH
ADEQUATE VENTILATORY SUPPORT
 HYPERKALEMIA
 HYPERMAGNESEMIA
 TRICYCLIC ANTI DEPRESSANT POISONING
 SODIUM CHANNEL BLOCKER POISONING
Indications as per A.H.A.
Sodium bicarbonate is further indicated in the
treatment of certain drug intoxications, including
barbiturates (where dissociation of the
barbiturate-protein complex is desired), in
poisoning by salicylates or methyl alcohol and in
hemolytic reactions requiring alkalinization of the
urine to diminish nephrotoxicity of hemoglobin and
its breakdown products.

17. How do I give soda bicarb
×
 Indication : if pH is less than 7.15
in DKA ( less than 7.1 and not improving )
 HCO
3 required = half of BW × ( 15 – HCO
3 )
 Dilute 4 to 6 times give over 2 hours
 Diluent : water for injection/5%dextrose
Ensure adequate ventilation

18. carbicarb, an
equimolar mixture of
sodium bicarbonate and
sodium carbonate.
Carbonate preferentially
combines with hydrogen
ions resulting in production
of bicarbonate rather than
CO
2. Carbonate can also
combine with carbonic acid,
a reaction which also
produces bicarbonate. Thus
the acidosis is titrated
without the production of
CO2 or the lowering of
intracellular pH.

ALTERNATIVE

19.  Post resuscitation ..role of Soda Bicarbonate ?
 I don’t have ABG facility and the patient is in shock
Should I give Soda Bicarbonate
 Child with diarrhea and shock I would like to add S.B..
 to normal saline bolus , comment
 If the child admitted with me has received large dose of
 S.B. what should I monitor ?
 How do I dilute S.B., Rate of infusion
 Role of S.B. in wide anion gap acidosis
 Intratracheal administration for treatment of metabolic A
 Can S.B. be used for treatment of hyponatremia ?
( equivalent to 6 % saline,7.5 % contains 0.9 mEq./ml)

FAQ,S ………………………….

20. OVERDOSAGE:
Should alkalosis result, the
bicarbonate should be stopped
and the patient managed
according to the degree of
alkalosis NORMAL SALINE may
be given, potassium chloride is
indicated if there is
hypokalemia. Severe alkalosis
may be accompanied by
hyperirritability or tetany and
these symptoms may be
controlled by calcium gluconate.

22. THANKS