Sodium bicarbonate push

  1. I pushed 3amps of bicarbonate through a midline catheter per doctors orders and about an hour prior to transferring a pt to a different unit. We drew it up in 10ml syringes and did not dilute it. The pt's BP shot up to over 200, but we were able to get it down within minutes. My question is this- after the fact, I've read it should be diluted and given slower. Could I have potentially harmed this pt, and how long after administration would it be clear if she was experiencing adverse effects. I haven't been able to find these answers on online or in my books. This pt was acidotic, on a vent with spontaneous breathing. I'm a new grad and feel lost in these high pressure situations, and don't really know how to manage checking my actions before I perform them when there's really no time to do so, so I end up relying on veterans' advice. I realize this could be very unsafe practice. Our charge nurse is off unit a lot, and I've been told to lean on the veteran resources, but still, if it's my pt it's my butt on the line.
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    About lvcrn

    Joined: Mar '16; Posts: 5; Likes: 2

    23 Comments

  3. by   offlabel
    150 cc's in 10 cc increments of bicarb is pretty reasonable, I think. The 8.4% amps are for rapid bolusing. I wonder how acidotic your patient was? The bump in blood pressure was most probably due to the change in blood pH creating a situation where the patient's catecholamine's could actually work, or work better. Epi, norepi etc. don't work as well in the presence of severe acidosis.
  4. by   AMR21
    If I have time and access I like to give an amp over 10 min.
  5. by   lvcrn
    Thank you for responding. I've been stressing that I maybe made an error in the way I administered it. She came to me with pH 7.1, bicarbonate around 18 if I remember correctly, and CO2 in normal range. It was decided not to wean her off the vent as we'd hoped, so when the pressure shot up we started propofol (not running due to the attempt to wean post surgery) and gave 5 of labetalol. Pressure was back to normal in minutes and stayed down until I transferred her an hour later, no signs of extravasation. I didn't get another ABG prior to transfer unfortunately, so I'm disappointed to not know what the impact was. Thanks again, being new is stressful, but next time I will double check before I administer something, if I'm feeling unsure about it.
  6. by   Pheebz777
    Sodium Bicarb (that I know of) comes in the pre-filled 50ml syringe or comes in the 50ml vial. I've never heard of having to dilute the bicarb any further prior to administration. Did yours come in that preparation?

    Anyway, hypotension is common in the setting of acidoses and bringing the PH level up would improve the blood pressure.
  7. by   lvcrn
    Thanks for the info. Yes, they were 50ml vials. The BP spike took me by surprise, but I'm relieved to know it's commonly given undiluted! I will double check my administration guidelines more thoroughly the next time though!!
  8. by   Nalon1 RN/EMT-P
    Interesting post.
    I was going to say that Bicarb does not cause HTN, but did not think about acidosis causing hypotension. Fixing the acidosis now allows the patients body to be able compensate for the low BP, but then end up causing HTN.
  9. by   Julius Seizure
    In young children and babies, we dilute bicarb with equal parts of NS, but it isn't needed in adults.
  10. by   juan de la cruz
    IV push sodium bicarbonate (8.4%, 50 ml, bristojet syringe) is usually indicated in Code Blue situations. It's not directly listed in the ACLS algorithms but is indirectly alluded to when you look for Reversible Causes in the Cardiac Arrest Algorithm. Remember the 5 H's and 5 T's where Hydrogen Ion means Acidosis? that's an indication when you would push IV sodium bicarbonate.

    However, I've seen some surgical specialties particularly Adult Cardiac Surgery use IV push sodium bicarbonate in their fresh post-op patients with metabolic acidosis that are not even on the verge of cardiac arrest. Metabolic acidosis affects cardiac function negatively and an acidic medium also makes pressors (except vasopressin) not work well. It does almost instantaneously make hemodynamics better in this subset of patients, hence, the transient rise in BP you saw.

    There is a caveat though because sodium bicarbonate as an IV push is actually short acting (8-10 minutes in some literature as far as duration) so I guess it's more of a temporizing measure until the reason for the acidemia is sorted out and corrected. You also can't push the bristojet too fast anyway as it's a 50 ml syringe not unless you are injecting it on to an introducer catheter/Cordis or you have really strong fingers.

    In many cases, you could use sodium bicarbonate infusion in patients with metabolic acidosis and the results would be more sustained though you run the risk of contributing to fluid overload in patients who have poor kidney function and dwindling urine output.
  11. by   hotcoffee
    From what I have read there is no evidence that pushing bicarb is helpful. We do it at my job fairly often. I don't have a good grip on the physiology. After you inject the nahco3 you get h20 and co2 and the patient gets a bunch of sodium.
    this link is interesting 8.7 Use of Bicarbonate in Metabolic Acidosis
  12. by   Greenclip
    I push bicarb all the time...pushed 3 amps the other day for a patient whose bicarb was 4, and then started a bicarb drip.

    The very first time I gave bicarb, I was off preceptorship only a couple of weeks. It was not a crunch situation. I asked the most senior nurse on the unit how to give it, and she told me to just push it in! You're right, in many situations you have to rely on the advice of veterans, especially when things need to happen fast.

    Keep in mind that ICU nursing is a team sport!
  13. by   MunoRN
    Quote from hotcoffee
    From what I have read there is no evidence that pushing bicarb is helpful. We do it at my job fairly often. I don't have a good grip on the physiology. After you inject the nahco3 you get h20 and co2 and the patient gets a bunch of sodium.
    this link is interesting 8.7 Use of Bicarbonate in Metabolic Acidosis
    There are certainly types of acidosis where bicarb will be of little use, such as anion gap acidosis (ie DKA), and isn't of much benefit in only mild bicarb deficient acidosis, but if you're patient is 6.9, they will absolutely benefit from not being in cardiac arrest.
  14. by   MunoRN
    Quote from juan de la cruz
    IV push sodium bicarbonate (8.4%, 50 ml, bristojet syringe) is usually indicated in Code Blue situations. It's not directly listed in the ACLS algorithms but is indirectly alluded to when you look for Reversible Causes in the Cardiac Arrest Algorithm. Remember the 5 H's and 5 T's where Hydrogen Ion means Acidosis? that's an indication when you would push IV sodium bicarbonate.

    However, I've seen some surgical specialties particularly Adult Cardiac Surgery use IV push sodium bicarbonate in their fresh post-op patients with metabolic acidosis that are not even on the verge of cardiac arrest. Metabolic acidosis affects cardiac function negatively and an acidic medium also makes pressors (except vasopressin) not work well. It does almost instantaneously make hemodynamics better in this subset of patients, hence, the transient rise in BP you saw.

    There is a caveat though because sodium bicarbonate as an IV push is actually short acting (8-10 minutes in some literature as far as duration) so I guess it's more of a temporizing measure until the reason for the acidemia is sorted out and corrected. You also can't push the bristojet too fast anyway as it's a 50 ml syringe not unless you are injecting it on to an introducer catheter/Cordis or you have really strong fingers.

    In many cases, you could use sodium bicarbonate infusion in patients with metabolic acidosis and the results would be more sustained though you run the risk of contributing to fluid overload in patients who have poor kidney function and dwindling urine output.
    I've never heard of sodium bicarb as having what can be described as a "half-life", it's a normally occurring electrolyte, so it's similar to saying potassium or sodium has a "half life". It will go through metabolism and eventual excretion, but it doesn't become inert in a predictable period of time.

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