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Charleston, SC

jimmy@pharmacyfridaypeals.com

Sodium Bicarbonate for Hyperkalemia in the Emergency Department

Introduction

  1. Sodium bicarbonate was previously recommended for hyperkalemia treatment and was once considered a first-line agent for transcellular shift.
  2. Studies evaluating the beneficial effects of sodium bicarbonate used an isotonic infusion commonly  ~ 150 mEq/ 1000ml
  3. Hypertonic sodium bicarbonate or “amp of bicarb” has an osmolality of 2000 mOsm, about 7x higher than plasma.
  4. There’s controversy as to whether hypertonic sodium bicarbonate is beneficial for the acute treatment of hyperkalemia due to modifications in mechanism of action.
 Pharmacology
 Sodium Bicarbonate 
Dose0.5-1 mEq/kg IV bolus 50-250 mEq hr Infusion
AdministrationHypertonic 8.4 % (50mEq/50 ml)  Slow IV push over  3-5 minutes   Isotonic Infusion 1.4% (150 mEq/L): 150-500 ml/hr x 2-6 hours
PK/PDOnset IV: 0.5-4 hours Duration IV: 4-6 hours Excretion: Urine (<1%)
Adverse EffectsHypocalemia Injection site extravasation Intracellular acidosis (without adequate ventilation) Hypernatremia Hyperosmosis Shift O2 release by hemoglobin
CompatibilityIncompatible with Epinephrine, calcium chloride, calcium gluconate,
 Sodium Bicarbonate Proposed Mechanisms of Action
Transcellular shiftIndirect movement of potassium into cells via an H+/K+ exchange and HCO3-/K+ cotransport. 
Renal ExcretionK+ channels in the distal nephron are down-regulated by acidosis and up-regulated by alkalosis,  Sodium bicarbonateà Alkalization agentà K+ Channel upregulationà↑ Excretion of K+
DilutionVolume expansion leads to less K+ per liter

Jlpruitt@gmh.edu                                                                                                                                                            For educational purposes only

Overview of Evidence
Author, year Design/ sample sizeIntervention & ComparisonOutcome
Ngugi, 1997Case Series n=10Insulin- 10 unit + glucose 25g ________________________________ 8.4% SB- 50 ml over 15 mins ________________________________ Salmeterol- 0.5 mg IV Combination of eachSB led to an average ↓ in K+  by 0.5 mEq/L drop at 30 minutes   Combination therapy with insulin/dextrose + Salmeterol was more effective than those with SB
Kim,1996Observational n=128.4% SB-120 mEq/L x 1 hr ________________________________ Insulin drip- 0.5 unit/kg/min x 1 hr    SB led to ↑ of serum bicarbonate but no change in serum K+ (6.4 mEq/L to 6.3 mEq/L)   Insulin drip led to ↓ of serum K+ (6.3 mEq/L to 5.7 mEq/L)   Combination of insulin drip + SB led to ↓ in serum K+ (6.2 mEq/L to 5.2 mEq/L)
Blumberg, 1992Observational n=128.4% SB (240 mEq/hr) x 1hr then with 1.4% SB (30 mEq /hr) x 5 hrsNo change in K+ at hour 1 or 2    ↓ in serum K+ by 0.6 and 0.74 mEq/L at hours 4 and 6 respectively, of which approximately half was calculated to be due to ECF volume expansion    Peak T-waves in the ECG of 7 patients disappeared after one hour only in one patient
Gutierrez, 1991Observational n=181.4% SB in H2O (1mEq/kg) over 2 hrs ________________________________ 8.4% SB(1mEq/kg) over 5 mins  Isotonic SB led to in bicarbonate by 3 mEq/L and ↓ K+ by 0.35 mEq/L at 180 min   Hypertonic SB led to slight ↑ in bicarbonate and Osmolality and not change in K+ levels
Blumberg, 1988Observational n=108.4% SB drip x 1 hr ________________________________ 1.4% SB drip x 1 hr ________________________________ Epinephrine drip 0.05 mcg/kg/min x 1 hr ________________________________ Insulin drip 0.5 unit/kg/min x 1 hrHypertonic and isotonic IV SB = ↑plasma bicarbonate and pH,  but no impact on K+(5.66 versus 5.83 mEq/L) before vs after
Fraley, 1977Observational n=14SB 89-134 mEq/1000ml D5W over 4-6 hours ________________________________ D5W 1000ml over 4-6 hoursIn SB infusion group, serum K+ ↓ by about 0.15 mEq/L for every 1 mEq/L in bicarbonate   D5W was not effective in reducing potassium levels
Schwarz, 1959Case Series N=45% SB drip over 2-6 hoursResolution of EKG abnormalities in all patients; 2/4 died within 24 hours

References

  1. Sodium Bicarbonate. Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved August 29, 2019, 2018, from http://www.micromedexsolutions.com/
  2. Gutierrez R et al. Miner Electrolyte Metab. 1991;17(5):297-302. [PMID: 1668124]
  3. Fraley DSet al. Kidney Int. 1977 Nov;12(5):354-60. [PMID: 24132]
  4. Blumberg A et al. Am J Med. 1988 Oct;85(4):507-12. [PMID: 3052050]
  5. Blumberg A et al. Kidney Int. 1992 Feb;41(2):369-74. [PMID: 1552710 ]
  6. Kim et al. Nephron. 1996;72(3):476-82. [PMID: 8852501]
  7. Ngugi NN et al. East Afr Med J. 1997 Aug;74(8):503-9. [PMID: 9487416]
  8. Long B et al. J Emerg Med. 2018 Aug;55(2):192-205. [PMID: 29731287]

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