The Role of Sodium Bicarbonate in the Management of Some Toxic Ingestions

Abstract

Adverse reactions to commonly prescribed medications and to substances of abuse may result in severe toxicity associated with increased morbidity and mortality. According to the Center for Disease Control, in 2013, at least 2113 human fatalities attributed to poisonings occurred in the United States of America. In this article, we review the data regarding the impact of systemic sodium bicarbonate administration in the management of certain poisonings including sodium channel blocker toxicities, salicylate overdose, and ingestion of some toxic alcohols and in various pharmacological toxicities. Based on the available literature and empiric experience, the administration of sodium bicarbonate appears to be beneficial in the management of a patient with the above-mentioned toxidromes. However, most of the available evidence originates from case reports, case series, and expert consensus recommendations. The potential mechanisms of sodium bicarbonate include high sodium load and the development of metabolic alkalosis with resultant decreased tissue penetration of the toxic substance with subsequent increased urinary excretion. While receiving sodium bicarbonate, patients must be monitored for the development of associated side effects including electrolyte abnormalities, the progression of metabolic alkalosis, volume overload, worsening respiratory status, and/or worsening metabolic acidosis. Patients with oliguric/anuric renal failure and advanced decompensated heart failure should not receive sodium bicarbonate.

83-year-old Woman with a Fever and Emesis

“…Once the metabolic acidosis develops, more of the salicylate is in its protonated form and able to create significant toxicity. 22 This principle is important for understanding both why we order certain labs and how we treat salicylate toxicity.…”

“…Hypokalemia promotes the resorption of potassium in the distal tubule via a potassium-hydrogen ion pump. 22 As the kidney tries to retain potassium, the urine becomes more acidotic and does not favor urinary excretion of the salicylate. Glucose is important to measure because neuroglycopenia can happen at normal glucose level, 14 , 15 and it is preferable for a toxic patient to be normo- to hyperglycemic.…”

“…Alkalization is achieved with a bolus (1–2 milliequivalents per kilogram [meq/kg]) and infusion (100–150 meq in dextrose 5% sterile water) of sodium bicarbonate with titration to a urine pH of 7.5 to 8. 22 As previously discussed, potassium levels must be monitored and normokalemia maintained to effectively keep the urine basic. Urine alkalization to a pH of 7.5–8.0 increases urinary excretion of salicylates significantly.…”

Review on The Effects of Adulterants on Drugabuse Testing in Urine Samples

“…****Food or liquids that are highly acidic (such as vinegar) or basic (such as sodium bicarbonate) can produce sufficient changes in urine pH to interfere with immunoassay screening procedures. Acidification or alkalization can affect the metabolism and rate of clearance for drugs (Mirrakhimov et al, 2017). For example, Amphetamine as a basic drug, 74%of the parent compound is excreted in urine that is slightly acidic.…”

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“…Sodium bicarbonate (SB) has been considered as a safe and effective therapeutic agent when given in the recommended doses and is relatively free of serious side effects [23]. It is an ideal choice of buffer solution in different metabolic and respiratory acidosis such as lactic acidosis, ketoacidosis, drug toxicities and acidosis due to pathogens [23,24].…”