In this episode, I’ll discuss the alternatives to sodium bicarbonate given the current drug shortage.



This isn’t the first time we’ve had to deal with a sodium bicarbonate shortage. Back in 2012 there was also a bicarb shortage…but this time it is more complicated. The two alternatives to sodium bicarbonate – sodium acetate and THAM are in short supply and discontinued, respectively.

I reviewed the use of sodium bicarbonate in critical care in episode 138.

The good news is that actual legitimate uses of sodium bicarbonate in critical care are few and far between.

The bad news is that sodium bicarbonate is frequently given in circumstances where it has no to little effect.

The habit of using sodium bicarb for cardiac arrest, DKA, contrast-induced nephropathy, rhabdomyolysis, hyperkalemia, or respiratory acidosis can be difficult to break. But the possibility of not having any sodium bicarb available when it is actually needed might be enough to change practice.

Perhaps the toughest practice to change is giving sodium bicarbonate in the setting of cardiac arrest. A review of literature and ACLS guidelines concluded:

Although many studies have shown little/no benefit and perhaps harm from administration of sodium bicarbonate (SB) for rapid correction of acidemia accompanying cardiac arrest, and the latest ACLS guidelines published by the AHA do not recommend routine administration, SB is still used as part of resuscitation in cardiac arrest. Additional research is needed to elucidate further the effects of SB on organ function, on the likelihood of ROSC and on survival in patients resuscitated from cardiac arrest. An objective reappraisal of the use of SB or other buffer agents and perhaps on an appropriate “therapeutic window” for use of SB in cardiac arrest patients is warranted.

When sodium bicarb is not available, sodium acetate can be given instead. 1 mEq sodium acetate can be used to replace 1 mEq sodium bicarbonate. However, sodium acetate needs to be given slowly – over 15 to 20 minutes – to avoid the risk of hypotension and cardiac instability. The slow rate of infusion limits the usefulness of sodium acetate in critical scenarios such as cardiac arrhythmias or toxicologic emergencies.

In order to get through this period of shortage, conserve sodium bicarb by seeking alternatives for the following conditions:

Metabolic, respiratory, or diabetic acidosis; treat the underlying cause.

Rhabdomyolysis; use normal saline instead.

Hyperkalemia; use calcium gluconate or chloride to stabilize myocardium, insulin+dextrose to hide potassium from the heart, then remove excess potassium from the body.

Prevention of contrast-induced nephropathy; use normal saline instead.

Cardiac arrest; follow ACLS protocols instead.

Reserve sodium bicarbonate and sodium acetate supplies for tricyclic, aspirin, methotrexate, and phenobarbital toxicity.

If you are completely out of sodium bicarb and sodium acetate, consider the following alternatives for drug toxicity:

Cardiac arrhythmias from tricyclic toxicity: Use Hypertonic saline. 1 mL of 8.4% sodium bicarb contains the same amount of sodium as about 2 mL of 3% saline. Use 3% NaCl 2-4 mL/kg per dose, giving approximately 1-2mEq of sodium per kg.

Methotrexate or phenobarbital toxicity: Consider acetazolamide, 500 mg every 6 hours followed by enteral sodium bicarbonate.

Quinidine-induced torsades: No other treatment will alkalize the serum quickly beside sodium bicarb/acetate. Use other treatments for torsades such as magnesium and electricity.

If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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