Sodium Bicarbonate in Cardiac Arrest

Introduction

Out-of-hospital cardiac arrest (OHCA) remains a leading cause of mortality and a substantial issue of public health concern worldwide.
Sodium bicarbonate (SB) administration has been considered an important part of treatment for severe metabolic acidosis in cardiac arrest, because based on pathophysiologic considerations, normalization of extracellular and intracellular pH was considered a meaningful endpoint of resuscitation.
Correction of metabolic acidosis with SB was recommended by early advanced cardiac life support (ACLS) guidelines published in 1973, and SB was the medication most frequently used during cardiac arrest until mid-1980s
The 2010 ACLS Guidelines for adults published by the American Heart Association (AHA) state that “Routine use of sodium bicarbonate is not recommended for patients in cardiac arrest” (class lll recommendation, based on level of evidence (LOE) B)

Pharmacology

Dose		0.5-1 meq/kg/dose • Repeat doses should be guided by arterial blood gases
Administration		IV injection during cardiac arrest
PK/PD		Onset Iv: Rapid Duration IV: 8-10mins Excretion: Urine (<1%)
Adverse Effects		Hypocalcemia Intracellular acidosis (without adequate ventilation) HYPERNATREMIA Hyperosmosis Shift O2 release by hemoglobin
Compatibility		Sodium bicarbonate solution may inactivate catecholamines such as epinephrine

May decrease of the biological effect of epinephrine to 77- 82 % of nonalkaline solution
not powered

Overview of Evidence

Author, Year	Design/ sample size	NaHCO3 regimen	Outcome
Chen YC, 2018	Observational/ n=5589	Not reported	Sodium bicarbonate during ED resuscitation was significantly associated with an increased rate of survival to hospital admission.
Kawano T, 2017	Prospective observational/ n=13,865	Not reported	In OHCA patients, prehospital SB administration was associated with worse survival rate and neurological outcomes to hospital discharge.
Ahn S, 2017	RCT/ n=50	50 mEq/L vs Placebo	No difference in sustained ROSC (4% vs 16%) or good neurological outcome (0% vs 4% , p=.1) SB had significant effect on pH (6.99 vs. 6.90, P=0.038) and bicarbonate levels (21.0 vs. 8.0 mEq/L)
Wang CH, 2016	Retrospective observational study/ n=109	Not Reported	SB was positively associated with sustained ROSC when serum potassium level was <7.9 mEq in IHCA Calcium and SB was positively associated with sustained ROSC when serum potassium level <9.4 mEq/L IHCA
Vukmir RB, 2005	RCT/ n=792	1 mEq/kg NaHCO3	Overall survival rate was 13.9% No difference in survival in those who received bicarbonate 2-fold increase in survival in arrest >15 min (32.8 vs 15.4)*
Bishop RL, 1976	Animal+human case studies/ n=6	1 mEq/kg of 7.5% sodium bicarbonate in dogs 0.5-0.9 mEg/kg in humans	Animal 1 mEq/Kg SB resulted in increases in the Pco2 (27→49), pH (7.38 →7.56) and the serum osmolality (309→349) Man 0.5-0.9 mEq/Kg SB resulted in increases in the Pco2 (24.5→38.8), pH (7.23 →7.48) and the serum osmolality (308→343)

References

Sodium bicarbonate. Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved October 11, 2018, from http://www.micromedexsolutions.com/
Bishop RL, et al. Sodium bicarbonate administration during cardiac arrest. Effect on arterial pH PCO2, and osmolality. JAMA. 1976 Feb 2;235(5):506-9.
Vukmir RB, et al. Sodium bicarbonate in cardiac arrest: a reappraisal. Am J Emerg Med. 1996 Mar;14(2):192206.
Vukmir RB, et al. Sodium bicarbonate improves outcome in prolonged prehospital cardiac arrest. Am J Emerg Med. 2006 Mar;24(2):156-61.
Wang CH,et al. The effects of calcium and sodium bicarbonate on severe hyperkalaemia during cardiopulmonary resuscitation: A retrospective cohort study of adult in-hospital cardiac arrest. Resuscitation. 2016 Jan;98:105-11.
Ahn S, et al. Sodium bicarbonate on severe metabolic acidosis during prolonged cardiopulmonary resuscitation: a double-blind, randomized, placebo-controlled pilot study. J Thorac Dis. 2018 Apr;10(4):22952302
Kawano T, et al. Prehospital sodium bicarbonate use could worsen long term survival with favorable neurological recovery among patients with out-of-hospital cardiac arrest. Resuscitation. 2017 Oct;119:63-69.
Chen YC, et al. The association of emergency department administration of sodium bicarbonate after out of hospital cardiac arrest with outcomes. Am J Emerg Med. 2018 Mar 5. pii: S0735-6757(18)30187-6.