Critical Care Society of
Southern Africa

8,5% Sodium Bicarb shortage 22 Sept 2022Suggested rational use of sodium bicarbonate and alternatives during nationwide 8.5% sodium bicarbonate shortage

8.5% sodium bicarbonate (NaHCO₃/Sodabic) is an alkaline solution used to treat/increase pH in patients with severe metabolic acidosis and certain other situations. During the expected nationwide shortage of 8.5% 50ml sodium bicarbonate solution the CCSSA would like to suggest alternatives as well as rational use of NaHCO₃ and the 50ml 8.5% solution.

With regard to the treatment of metabolic acidosis, there is no evidence-based role for the routine use of sodium bicarbonate to treat adult critically ill patients with metabolic acidosis. The use of sodium bicarbonate to treat metabolic acidosis has shown no mortality benefit across multiple cohorts of critically ill adult patients. Recently a subgroup analysis of the BICAR-ICU study showed a reduced mortality rate with the use of sodium bicarbonate in patients with severe metabolic acidosis (pH < 7.2) and acute kidney injury (AKIN grade 2-3). This finding is highly susceptible to a type I statistical error. As such, even in this subgroup of patients, the use of sodium bicarbonate is not standard of care but may be considered by the treating clinician until further studies confirm or refute this finding. Thus, the use of sodium bicarbonate for treatment of metabolic acidosis, during a nationwide shortage of sodium bicarbonate needs to be carefully considered and should preferably be reserved for situations where an outcome benefit has been demonstrated.

Potential indications for sodium bicarbonate therapy include but are not limited to:

• Severe metabolic acidosis, especially in the following scenarios

–       With associated renal failure

–       Drug-induced lactic acidosis (pH <7.1, bicarbonate <6mmol/l)

–       Diabetic ketoacidosis (initially, if pH ≤ 6.9)

–       Where dialysis is not an option

–       Where myocardial depression/lack of response to inotropes is suspected

• Liver transplant surgery
• Severe life-threatening hyperkalaemia
• Cardiac arrest
• Tricyclic antidepressant overdose
• Alkalinisation of the urine in salicylate poisoning

Alternatives to 8.5% 50ml NaHCO3 include:

• 4.2% NaHCO₃, 200ml available from Adcock Ingram. The 8.5% solution of NaHCO₃provides 1mmol/ml of HCO3-, whereas the 4.2% solution provides 0.5mmol/ml of HCO₃^–. Thus the required dose of 4.2% NaHCO₃ will be double the volume than when using 8.5% NaHCO₃. Please beware of fluid overload
• Dialysis
• Shohl’s solutions (If able to take orally)

o   Solution containing 140 g citric acid and 98 g hydrated crystalline salt of sodium citrate in distilled water to make 1000 mL

• Experimental data suggest that sodium chloride solutions may have equivalent efficacy to NaHCO₃in the treatment of tricyclic antidepressant overdose. If NaHCO₃ is not available, it is reasonable to consider hypertonic saline