soda bi carb 50 years...

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SodA Bi caRB Revisited Dr Vishram Buche Director, PICU Central India’s CHILD Hospital & Research Institute, NAGPUR Email: vbuche@gmail.com Cell : 09823017254

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More than 50 years of Soda Bi Carbonate………

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.... Sodium bicarbonate: first commercially produced in the late 1950’s 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 Is it a compensatory Mechanism…? Does it do any good ? Any Harm ? At what level to intervene ? Impaired acid excretion

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Acidemia of Metabolic Acidosis Suppresses Cardiac Contractility Releases Catecholamine Ionotrophic Effect >7.2 <7.2 Depressed myocardial contractility Decreased catecholamine efficacy Arrhythmias Pulmonary vasoconstriction Hypotension Depressed Myocardial Function

Soda-Bi-Carb…… : 

Soda-Bi-Carb…… .…Adverse-Effects

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Deleterious effects…

Hypertonicity… Hyperosmolality : 

Hypertonicity… Hyperosmolality 7.5% , 8.4%, 4.2% Na = HCO3 = 0.9 mEq/ml Osmolality = 1800 pH = ? 1ml produces 22 ml CO2 Medical Chemistry of NaHCO3 Normal serum osmolality is around ….290 1800 / 6 = 300 , that’s why ideal dilution of Soda-Bi-Carb should be 6 times 8

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Intracellular acidosis…. 1 ml NaHCO3 Gives 22 ml CO2 NaHCO3 = Na + HCO3 H+ + HCO3 H2O + CO2

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PaO2 …60 mmHg 7.4 7.8 7.0 Impaired tissue oxygenation with correction of acidemia…... Hb. Sat.% 100% 80%

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Oxygen delivery 24 to 48 hrs Low 2-3 DPG levels Secondary to reduced glycolysis Direct effect of pH on Hb ? affinity of O2 ACIDOSIS……………. OXYGEN DELIVERY Acute acidemia facilitates oxygen delivery chronic acidemia hampers oxygen delivery Correcting acute acidemia could be more dangerous..!!

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Experience is the ability to make the same mistake repeatedly with increasing confidence

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Case 1………………… 16 yrs old boy with diarrhea and LRI is in shock His ABG is ……. pH ……7.01 Pco2 …36 HCO3…5.5 WOULD BICARB BE INDICATED ? NO

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Case 2…… 15 yr…Girl Diarrhoea , Jr resident noted that the she is moderately Dehydrated and had R/R of 68 / min. A Bolus of N-saline was given followed by a dose of bicarb , thinking that the girl may be acidotic. After about 4 hours she has seizures . Sugar normal and so was calcium , seizure were controlled but recurred Again ………………. Ionic calcium low

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CASE 3…………. DKA WITH RT LOWER LOBE CONSOLIDATION AND HYPOXIA pH….7.016 CO2 ……6 BICARB..6 PO2 …..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 CO2 …. 34 BICARB…18 PO2 …..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 CO2 …14 BICARB..9 PO2 …..45 5 HOURS AFTER …………………LACTIC ACIDOSIS

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Rapid correction of acidosis shifts curve to left……..tissue hypoxia Mild hypotension Diabetics have low 2.3. DPG Soda bicarb. promotes lactic acidosis What can Happen with Mr Soda-Bi-Carb ? 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 pH < 7.0 . Thus the administration of sodium bicarbonate to patients with diabetic ketoacidosis cannot be recommended at any pH ( class 1 )

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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

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Severe Metabolic Acidosis with adequate ventilatory Support Hyperkalemia Hypermagnesaemia Tricyclic antidepressant drug poisoning Sodium channel blocker poisoning Indications as per A.H.A…………. Sodium bicarbonate indicated ….. In the treatment of certain drug intoxications… Barbiturates (where dissociation of the barbiturate-protein complex is desired), Poisoning by salicylates or methyl alcohol . In hemolytic reactions (requiring alkalinization of the urine to diminish nephrotoxicity of hemoglobin and its breakdown products.) In Nutshell….. Role is doubtful AND not justified in all Wide anion Gap Metabolic Acidosis (ORGANIC ACIDOSIS) e.g. Lactic Acidosis, DKA, Uremic Acidosis, Alcoholic KA. But …… Well justified in Non Gap Metabolic Acidosis (INORGANIC ACIDOSIS..True HCO3 deficit) e.g. Severe Diarrhoea, RTA, CRF.

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How do I give soda bicarb…..? × Indication : if pH is less than 7.10 in DKA ( less than 7.1 and not improving ) HCO3 required = half of BW × ( 15 – HCO3 ) Dilute 4 to 6 times give over 2 hours Diluent : water for injection / 5%dextrose

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carbicarb, an equimolar mixture of NaHCO3 and NaCO3. Carbonate preferentially combines with H ions resulting in production of HCO3 rather than CO2. 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

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During /Post resuscitation ..role of NaHCO3 ? I don’t have ABG facility and the patient is in shock Should I give S.B. ? Child with diarrhoea 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 …………? .. CO & BP fell sooner when NaHCO3 was used to treat lactic acidosis (Graf 1985 Science) .. NaHCO3 corrected arterial metabolic acidosis, but led to a decrease in intramyocardial pH, and reduced the likelihood of successful resuscitation (Kette 1990 Circulation) .. Hypertonic solutions adversely affect cardiac resuscitation efforts by reducing CPP (Kette 1991 JAMA)

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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.

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Experience is a wonderful thing. It enables you to recognize a mistake when you make it again.

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saaoDa -CARB… -BI BYE SODA

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Rally………………….

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THANKS…