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Sodium bicarbonate

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Indications, dose and administration

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  1. Emergency neonatal resuscitation.
    1-2mmol/kg by slow IV push.
  2. Metabolic acidosis 
    1. Documented metabolic acidosis during prolonged resuscitation after establishment of effective ventilation. Administer half calculated dose then assess need for remainder. Administered by slow IV infusion over 30 minutes.
    2. Bicarbonate deficit caused by renal or gastrointestinal losses. Slow correction orally.
      Sodium bicarbonate dose (ml) = base deficit x 0.6 x weight (kg).
  3. Persistent pulmonary hypertension of the newborn.
    0.25-0.50 mmol/kg/hour. Continuous IV infusion.
    Doses needs to be individualised and titrated according to response and to adverse effects (e.g. hypernatraemia)

Contraindications and precautions

  1. Respiratory or metabolic alkalosis.
  2. Not recommended for hypercapnia or hypernatraemic states.
  3. Caution in infants with renal impairment.
  4. Caution in preterm infants. Rapid infusion of hypertonic NaHCO3 has been incriminated in the pathogenesis of intraventricular haemorrhage in preterm infants.

Clinical pharmacology

Sodium bicarbonate is the alkali most frequently employed for correction of metabolic acidosis. The drug is well absorbed from the gastrointestinal tract. Between 20-50% of an orally administered dose can be recovered in the form of expired carbon dioxide. The apparent bicarbonate space has been estimated to be 74% of body weight (range of 37-134%). Thus calculations of bicarbonate dosage are based on an apparent volume of distribution of 0.3 to 0.6 L/kg. Bicarbonate is rapidly metabolised to carbonic acid which rapidly dissociates into water and carbon dioxide. The carbon dioxide is excreted via the lungs.

Possible adverse effects

  1. Venous irritation, soft tissue injury at the site of IV injection.
  2. Increased vascular volume, serum osmolarity, serum sodium.
  3. Hypercapnia and respiratory acidosis.
  4. Hypocalcaemia.
  5. Abdominal cramping, nausea, vomiting.
  6. Oedema, congestive heart failure.
  7. Hyperirritability, tetany.
  8. Intraventricular haemorrhage.

Special considerations

  1. The osmolarity of molar sodium bicarbonate (8.4%) is approximately 1800 mOsm/kg H20.
  2. The adverse effects of sodium bicarbonate are largely associated with the use of inappropriately excessive doses, infusion rate or concentrations of sodium bicarbonate. Some of these side effects, such as intracranial haemorrhage, may not be specific for sodium bicarbonate.
  3. The recommended rate of infusion is no more rapid than 1 ml of bicarbonate IV per minute.
  4. Paradoxical acidosis (intracellular, CSF) may occur. Carbon dioxide diffuses more readily across cell membranes than bicarbonate, thereby decreasing intracellular/CSF pH.

Management of Sodium Bicarbonate administration

Description

Clear solution (8.4%) 1 mmol/ml. No bacteriostat added.

Prescription

Slow IV injection and slow IV infusions are charted on stat page of drug chart.

Continuous IV infusion via syringe pump charted on fluid chart giving:

  • rate in ml/hour
  • dose in mmol/hour

Also charted on drug chart under continuous infusions giving:

  • amount of drug to be added
  • base fluid, type and volume
  • mmol/kg/ml
  • Continuous IV infusion via a volumetric infusion pump charted on fluid chart only stating molar sodium bicarbonate and volume to be added.

Administration

Slow IV Injection

  1. Administered by doctor / NS-ANP. In the emergency situation the nurse on the Neonatal IV Drug Register may administer under the direct supervision of the doctor present.
  2. Dilute prior to use 1:1 with sterile water for injection.
  3. Filter prior to administration through a 5 micron filter.
  4. Administer by slow IV injection. Rate not to exceed 1 mmol/minute.
  5. Incompatible with calcium. Compatible with NS, D5W, D10W.
  6. Stop IV fluids. Flush with NS before and after administration of sodium bicarbonate.

Slow IV Infusion

  1. Administered by a nurse with Neonatal IV Drug Certification.
  2. Dilute prior to use 1:1 with sterile water for injection.
  3. Filter prior to administration through a 5 micron filter.
  4. Administer by slow IV infusion over 30 minutes using a syringe pump.
  5. Incompatible with calcium. Compatible with NS, D5W, D10W.
  6. Flush with NS before and after administration of sodium bicarbonate.

Continuous IV Infusion

  1. Via syringe pump: Dilute prior to use on specific medical order. 
  2. Via IV fluid bag: Add to IV fluids as ordered by medical staff (incompatible with calcium in solution).

Oral

Give with feeds.

Observation and documentation

  1. Monitor for adverse reaction
  2. Monitor acid-base status
  3. Include volume in daily fluid intake. 

Storage

  • Unopened - at room temperature <30°C.
  • Discard ampoule after use.

Selected references

  1. Emergencies in the delivery room, in Fanaroff AA, Martin RJ (ed): Neonatal-perinatal medicine: disease of the fetus and infant, ed 4. St Louis, CV Mosby Co, 1988, pp336-378. 
  2. Howell JH. Sodium bicarbonate in the perinatal setting - revisited. Clin Perinatol 1987; 14:807. 
  3. Nairns RG, Cohen JJ. Bicarbonate therapy for organic acidosis: the case for its continued use. Ann Intern Med 1987; 106:615. 
  4. Roberts RJ. Drug therapy in infants: Pharmacologic principles and clinical experience. Philadelphia, WB Saunders Co, 1984, pp288-91. 

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Document Control

  • Date last published: 28 February 2001
  • Document type: Drug Dosage Guideline
  • Services responsible: ADHB Pharmacy, Neonatology
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years