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Stefan Johansson

Base deficit and the use of bicarbonate/buffer.

Sodium bicarbonate/buffer for metabolic acidosis during resuscitation? Please also post comments!  

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  1. 1. Sodium bicarbonate/buffer for metabolic acidosis during resuscitation? Please also post comments!

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I visited Hot Topics last year and one of the best lectures (according to me!) was held by Judy Aschner, about the use of sodium bicarbonate being principally useless (and could even have adverse effects).

Please click here to read an excellent review article on the topic by Aschner and Poland.

Unfortunately only the abstact is available for free, but the article is worth to order!

As many other units, we have a strong tradition to consider the use buffer, if pH is less than 7.25 and BE less than -5 (at least in in ELBW infants)

The article by Aschner and Poland has been subjected to some debate in our units. The major argument in favour of buffer is that we do not use sodium bicarbonate but Tribonat, which is a combination of trometamol (THAM), bicarbonate och acetate. The theoretical idea behind Tribonat is to achieve intracellular (THAM), extracellular (bicarb & acetate).

Personally, I have switched to a quite restrictive approach and rarely use buffer, but try to consider the etiology of the base deficit in the management of acid-base.

What's your experience and view upon the use of buffer?!

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Dear Stefan

It is true most of us are now more and more restrictive on using NaHCo3. I think the next version of NRP will also decrease their role in resuscitation.

Personally in our unit we started a restrictive policy about 1 year ago, I do agree the treatment of acidosis should be directed to the cause rather than giving NaHCO3.

We do not have tribonat or THAM in our country and I do not have experience in there use.

Thanks for this hint from hot topics, would you also elaborate more on therapeutic hypothermia in HIE (hot topics 2008 had a session on this issue)

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Guest maedmu

Dear,

We use sodium bicarbonate , when ph is below 7.2 , or bicarbonate below 12, but in any cases we use to prevent acidosis, We use in infusion around of four to six hours the question is its allright???, there are many studies that discourages the use of bicarbonate but we still use .... ,

Its an interesting topic

We dont have buffer in our country.

Thanks foir your commentaries

Manuel Munaico

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Dear All,

I am new to this forum.

In our unit it was frequently used on almost every baby 3-4 years back.

But recently the trend has changed and it is rarely used.

I prefer using it in sick VLBW babies, with PH below 7.2, and BD of more than -10.

Regards

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Dear All,

I´m am new to this forum. In my unit we very rarely use NaHCO3.

In the extremely premature mechanicaly ventilated child with an BE below -10 and a pH below 7,25 NaCHO3 is sometimes uses for a short time.

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Dear All,

We use NaHCO3 when we have "unvigorously" baby (Apgar score first min <3) and if he/she have not recovered by ventilation. Also, we use bicarbonate if the baby has significant metabolic acidosis + resp. acidosis and if he/she doesn't recover with changing parameters of ventilation. When is pH < 7,1 and BE> 10-11 , without resp. acidosis we use NaHCO3 during 30min (half of doses).

I read that article, it is fantastic.

And the question: what does happend with intracellular acidosis when we use bicarbonate in metabolic "blood" acidosis?

Another one: what with use of Ca in infusion in that babies, because in hypoxia and asphyxia Ca acts very important role? Hypocalcaemia is the sign of Ca level in blood, what is with Ca level in cells?

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so, what is more detrimental? the acidosis with less than 7.10 (pick a number) or the bicarbonate?

Check this out:

http://pediatrics.aappublications.org/cgi/content/abstract/122/4/831

The issue raised by the authors is rather that bicarbonate is useless.

Even, the authors write:

Indeed, there is evidence that this therapy is detrimental.
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sodium bicarbonate correction has been in use and it is a habit and habit does not change easily, even if there are evidence of harmful side effects. try and correct the underlying cause- fluid deficit / hypotension/ circulatory insufficiency and then if the pH is still low even with respiratory compensation use sodium bicarbonate, that is what we have been doing

I would pick the pH number <7.1, which more likely correlates with absolute hydrogen concentration rather than the base deficit, which is useful when you want correction to be done.

Edited by JACK
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We knew long time ago the possible adverse effects associated with the use of sodium bicarbonate as , intracranial hemorrhage,diminished oxygen delivery to tissues, worsening intracellular acidosis, aggravated myocardial injury, but always we give 1/2 correction , diluted dose over 20-30 minutes and when adequate spontaneous or assissted ventilation till we find the cause of metabolic acidosis . We restrict it to cases of severe metabolic acidosis in NICU in order to avoid these adverse effect . We stopped use it in delivery room since long time .The evidence of harm in the article need from us more attension and may be if go back to our files .

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Reading the evidence I am also very compelled not to use Bicarbonate as I am really concerned that we are harming the baby even more. The blood value might be fixed (mostly not for long) and intracellularly things are just getting worse. Yet with my back against the wall I might try it for effect, especially if I am suspecting Bicarbonate loss (renal, intestinal).

Just curious: are you buffering complete or half - do you dilute with destillated water and over what time do you give it?

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Just curious: are you buffering complete or half - do you dilute with destillated water and over what time do you give it?

This is a rather historical note from myself (since I hardly use buffer now): I was taught from my mentor to calculate the volume of buffer (Tribonat, mixture of trometamol and Sod-Bic) so it would target a BE of -5 ("then the baby will do the rest"). I guess that was a half-buffering approach. Buffer was usually used as extra volume, so the volume admin was not added in the water-balance calculations.

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well, We sort of agree about not to use it in the Delivery room.

Instead of finding a very convincing answer regarding the soidium bicarb, and after reading all the posts, I find myself facing more questions :

1- If not to use it in the DR ..would you consider it in resusitation of a newborn in the NICU ?

2-I personally rarley use it, and I try to buffer the base deficit by using blood or NS boluses, but then even NS boluses may cause IVH if were given quickly, so the question is shall we tolreate lower PH even down to 7.0 and deficit of -16 ? and shall the criteria of the PH and BE numbers change by different gestational ages or birht weight? I.e Full term resusitaion vs. VLBW.

3- how about increasing the TPN Acetate in kids with persisitent metabolic acidosis (like with mod to large PDA) or kids with continious NG suction like Gastroschisis ones?

4- using bicarb looks like using a big band-aid on a deep wound cut to cover it up to stop bleeding, but the cut may bleed again ..and we use bigger bandaid(more bicarb) ..until bleeding stops, now do u thing the bandaid did it ? or it was just a matter of time(with the help of fluid, dopa, fixing the respiratory acidosis, etc..) regardless of the bandaid-bicarb?

Thank you !

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Guest edtushe

We use very rarely bicarbonate during resuscitation efforts, only when acidosis is documented, after ABE blood sample. But we use it later during the treatment of babies in NICU

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i use it rarely,but how about PT baby on NCPAP with good o2 saturation but there is resp distress and metabolic acidosis .....i give him bolus of Ns and still PH <7.1 and BD >-8

and give him dopamin 5-10 mic and still

what isthe explanation of this,should i give NAHCO3

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According to ERC guidelines of resuscitation in the delivery room the aim of administering sodium bicarbonate during resuscitation is not to correct the blood acidosis in general but only to elevate the pH level  as close to the heart as possible to make the epinephrine receptors more "reactive" to it.

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Interesting point Agnieszka. I have heard this argument as well, but do you know of any evidence for this hypothesis?

Still I find it surprising with all the lack of evidence but possibly wide spread use, that no one has come up with a study so far (neither in adults or newborn..)

This is the only study I found (in adults), but I cant see if the study really ever started: http://clinicaltrials.gov/ct2/show/study/NCT01377337

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We do sometimes use bicarbonate in cases of persisting metabolic acidosis, especially when ionotropes (suprarenine, noradrenaline etc) are not working properly (inotropic support). In acidemia changes in ligand binding and pharmacological effects of inotropes may occur, therefore our goal is to ascertain a ph > 7,15.

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I am sorry for replying so late - here is the citation from the ERC manual for Newborn Life Support course ( 2010  edition ):

 

...Sodium bicarbonate

If there is no effective cardiac output, or virtually none, then reversing intracardiac acidosis may be helpful. This is certainly true in animal experiments35. You are not attempting to correct the baby's metabolic acidosis, you are merely trying to improve cardiac function by improving the pH of the blood within the heart.

 

And the evidence  article:

35 Daniel SS, Dawes GS, James LS, Ross BB, Analeptics and resuscitaton of asphyxiated monkeys Br Med J 1966 II 562-3 

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Whatever side we take...the most important point to remember is that ventilation should be excellent when using Bicarbonate...if ventilation is not optimal...then the CO2 released from Bicarb in vivo goes nowhere and paradoxically leads to increased acidosis !!!

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