Pulmonary, obstetric and electrolyte infusions
Sodium bicarbonate (NaHCO3) drip
NaHCO3
Dosing
| Start | Sodium channel blocker toxicity (TCA, QRS 100 ms or more): 50–150 mEq (1–2 mEq/kg) of 8.4% IV push, repeated until the QRS narrows, then an infusion if needed (AHA 2023). Salicylates: bolus, then the 150 mEq/L bag at 1.5–2 times maintenance. Hyperkalemia with acidosis: an add-on only |
|---|---|
| Titrate | Poisoning: to QRS narrowing and pH 7.50–7.55; salicylates: urine pH 7.5 or more (AACT 2004) with K replaced; severe acidosis: pH 7.30 (BICAR-ICU). Frequent gases, Na, K and ionized Ca |
| Maximum | Serum pH 7.50–7.55 and Na 150–155 (AHA 2023). Acidosis: suggested only at pH 7.2 or less with AKI, not for lactate alone (SSC 2026); BICAR-ICU gave 4.2% 125–250 mL (62.5–125 mEq) over 30 minutes, up to 1,000 mL (500 mEq) a day |
| Common bags | 150 mEq in 1,000 mL (0.15 mEq/mL); 100 mEq in 500 mL (0.2 mEq/mL) |
| Dose units | mEq/h |
Line and administration
- Pharmacy bags: 150 mEq in 1 L of D5W or sterile water; DKA below pH 7.0: 100 mEq of 8.4% in 400 mL sterile water, every 2 hours until pH is over 7.0 (2024 consensus)
- Never with calcium (precipitates) or catecholamines (inactivated) in the line; flush before and after
- 8.4% pushes are hypertonic vesicants: large vein, watch the site
Watch for
- Low K (it also stops urine alkalinization) and low ionized Ca (tetany, long QT)
- Hypernatremia and volume overload
- Each 50 mEq makes over 1 L of CO₂: raise ventilation, or PaCO₂ climbs and cells and CSF turn more acidic
Sodium bicarbonate: full drug monographIndications, mechanism, pharmacokinetics, cautions and every dose the app lists.
In the one-pagers
- Toxidromes and AntidotesCardiotoxic drugs: TCA, sodium channel blockers: Sodium bicarbonate 50–150 mEq IV, repeat to narrow QRS: QRS ≥100 ms: seizures; ≥160 ms: VT/VF
- CapnographyPatterns and causes: Sudden rise: ROSC, IV sodium bicarbonate, tourniquet release
- Mental Health: Meds and CommunicationAntidepressants in the ICU and serotonin toxicity: TCA overdose layers sodium-channel blockade on an anticholinergic toxidrome: coma, seizures, hypotension and a wide QRS with a tall terminal R wave in aVR. A QRS of 100 ms or more predicts seizures and 160 ms or more ventricular arrhythmias (Boehnert 1985). Give sodium bicarbonate 1–2 mEq/kg IV boluses until the QRS narrows, without pushing pH abo
- ACLS Algorithms in BriefDrugs in arrest: what the trials show: Sodium bicarbonate: No survival benefit in unselected arrest: Hyperkalemia, sodium channel blocker toxicity
- Rhythm GalleryVentricular rhythms and wide-complex tachycardia: A wide, slowish tachycardia in renal failure or overdose may be hyperkalemia or sodium-channel blockade (TCA: terminal R in aVR): calcium or sodium bicarbonate, not procainamide or amiodarone.
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Other pulmonary, obstetric and electrolyte infusions
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For education and exam preparation only. Follow your institution’s protocols. Study aid: check every dose against the order, the bag label, your pump library and your institution's protocol.