Usual Adult Dose for Metabolic Acidosis

Parenteral:
If acid-base status is available, dosages should be calculated as follows: 0.2 x weight (kg) x base deficit.

Alternatively:

HCO3 (mEq) required = 0.5 x weight (kg) x [24 - serum HCO3 (mEq/L)].

or

Moderate metabolic acidosis: 50 to 150 mEq sodium bicarbonate diluted in 1 L of D5W to be intravenously infused at a rate of 1 to 1.5 L/hour during the first hour.

Severe metabolic acidosis: 90 to 180 mEq sodium bicarbonate diluted in 1 L of D5W to be intravenously infused at a rate of 1 to 1.5 L/hour during the first hour.

If acid-base status is not available, dosages should be calculated as follows: 2 to 5 mEq/kg IV infusion over 4 to 8 hours; subsequent doses should be based on patient's acid-base status.

Oral:

Moderate metabolic acidosis: 325 to 2000 mg orally 1 to 4 times a day. One gram provides 11.9 mEq (mmoL) each of sodium and bicarbonate.

Usual Adult Dose for Diabetic Ketoacidosis

Although sodium bicarbonate is approved for the treatment of metabolic acidosis, data have shown that the use of this drug may be harmful in certain clinical settings such as lactic acidosis, acidosis with tissue hypoxia, uremia, severe cardiac dysfunction or arrest, and diabetic ketoacidosis.

Most experts only allow for its use when tissue perfusion and ventilation are maximized and the arterial pH is 7.1 or lower.

If sodium bicarbonate is used to treat diabetic ketoacidosis, the initial dosage is 50 mEq sodium bicarbonate in 1 L of appropriate IV solution to be given once.

Insulin therapy may obviate the need for bicarbonate therapy since it will promote glucose utilization and decrease the production of ketoacids.

Usual Adult Dose for Urinary Alkalinization

Parenteral:

50 to 150 mEq sodium bicarbonate diluted in 1 L of D5W to be intravenously infused at a rate of 1 to 1.5 L/hour.

Oral:

325 to 2000 mg orally 1 to 4 times a day. One gram provides 11.9 mEq (mmoL) each of sodium and bicarbonate.

The goal of therapy is to correct serum pH and increase the urinary pH to 8 in order to increase the renal excretion of toxic substances such as salicylates or lithium.

If the increase in urinary pH is inadequate, increasing the sodium bicarbonate in solution to 100 to 150 mEq/L may result in further alkalinization of the urine.

Usual Adult Dose for Dyspepsia

325 to 2000 mg orally 1 to 4 times a day.

Usual Adult Dose for Hyperkalemia

One ampule of 7.5% sodium bicarbonate (44.6 mEq HCO3 ion) may be administered slowly IV over 5 minutes and repeated at 10 to 15 minute intervals if ECG changes persist. The onset of action occurs within 30 minutes and the effect lasts for 1 to 2 hours. The resultant effect restores intracellular potassium levels to normal without decreasing total body potassium stores.

Circulatory overload and hypernatremia can occur when large volumes of hypertonic sodium bicarbonate are given. If hypocalcemia is present, seizures and tetany may occur as blood pH rises and the ionized free calcium decreases; hence, calcium should be given first. Hyponatremia will magnify the cardiac effects of hyperkalemia, and sodium bicarbonate can be used to treat this as well.

Usual Adult Dose for Asystole

1 mEq/kg slow IV initially, may repeat with 0.5 mEq/kg 10 minutes later one time, or as indicated by the patient's acid-base status.

Usual Pediatric Dose for Metabolic Acidosis

If acid-base status is available, dosages should be calculated as follows:
Infants and Children: HCO3 (mEq) required = 0.3 x weight (kg) x base deficit (mEq/L) OR HCO3 (mEq) required = 0.5 x weight (kg) x [24 - serum HCO3 (mEq/L)].

If acid-base status is not available, dosages should be calculated as follows:
Older children: 2 to 5 mEq/kg IV infusion over 4 to 8 hours; subsequent doses should be based on patient acid-base status.

Usual Pediatric Dose for Urinary Alkalinization

0 to 12 years: 1 to 10 mEq (84 to 840 mg)/kg/day orally in divided doses; dose should be titrated to desired urinary pH.

Greater than 12 to 18 years: 325 to 2000 mg orally 1 to 4 times a day. One gram provides 11.9 mEq (mmol) each of sodium and bicarbonate.

The goal of therapy is to correct serum pH and increase the urinary pH to 8 in order to increase the renal excretion of toxic substances such as salicylates or lithium.

If the increase in urinary pH is inadequate, increasing the sodium bicarbonate in solution to 100 to 150 mEq/L may result in further alkalinization of the urine.

Usual Pediatric Dose for Hyperuricemia Secondary to Chemotherapy

0 to 12 years:

Parenteral:
120 to 200 mEq/m2/day diluted in maintenance IV fluids of 3000 mL/m2/day; titrate to maintain urine pH between 6 and 7.

Oral:
12 g/m2/day divided into 4 doses; titrate to maintain urine pH between 6 and 7.

Usual Pediatric Dose for Asystole

1 mEq/kg slow IV initially, may repeat with 0.5 mEq/kg 10 minutes later one time, or as indicated by the patient acid-base status.

Renal Dose Adjustments

Due to the risk of hypernatremia, electrolyte shifts, and systemic pH changes, it is recommended that sodium bicarbonate be used with caution due to this patient's renal dysfunction. Close monitoring of this patient's plasma electrolytes and bicarbonate is recommended, particularly if dose increments are considered.

Liver Dose Adjustments

Due to the risk of hypernatremia, electrolyte shifts, and systemic pH changes, it is recommended that sodium bicarbonate be used with caution due to the patient's liver disease. Close monitoring of this patient's plasma electrolytes and bicarbonate is recommended, particularly if dose increments are considered.

Precautions

Sodium bicarbonate is contraindicated in patients with chloride loss from vomiting or from continuous gastrointestinal suction, who are receiving diuretics that are known to produce a hypochloremic alkalosis, with metabolic or respiratory alkalosis, with hypocalcemia in which alkalosis may produce tetany, hypertension, convulsions or congestive heart failure, and in patients in whom the administration of sodium would be clinically detrimental.

Dialysis

Sodium bicarbonate is removed by peritoneal dialysis. Bicarbonate has been commonly used in the peritoneal dialysate to raise the pH in patients in whom the standard pH of 5.5 causes abdominal discomfort on inflow.

Sodium bicarbonate is removed by hemodialysis. Bicarbonate has been commonly used in the dialysate bath to correct metabolic acidosis, and has been used preferentially over acetate for patients with marked hemodynamic instability due to sepsis or other causes, particularly patients requiring vasopressor support. Bicarbonate dialysate is also used for high-flux and high-efficiency dialysis with K/V greater than 5.5 mL/min/L.

Other Comments

A gradual rise in the plasma bicarbonate concentration up to the normal range over a 12 to 24 hour period is recommended as opposed to a rapid "correction" of the patient's entire bicarbonate deficit. Rapid correction of the deficit can cause hypokalemic cardiotoxicity in patients who are potassium-depleted, tetany in patients with renal failure or hypocalcemia or congestive heart failure in patients with poor left ventricular function due to the excess sodium load from this medication). Other possible side effects include systemic alkalosis and/or CNS acidosis. Further bicarbonate therapy depends on the patient's plasma bicarbonate level.

In patients with lactic acidosis, resolution of the event responsible for the acidosis is the primary treatment. While severe lactic acidosis can contribute to circulatory collapse, treatment with sodium bicarbonate may promote lactate production. In general, sodium bicarbonate may be beneficial if the plasma bicarbonate is less than 8 mEq/L or the systemic pH is less than 7.1.