Crisis and Sodium Bicarbonate

Insulinization with saline infusion for 2 hours is usually sufficient to halt ketosis and gluconeogenesis and begin reversing metabolic acidosis. Rarely, life-threatening acidosis exists with pH below 6.90. Blood pressure and cardiac output may be compromised. The anion gap may be approaching 40 mEq/dL, suggesting a coexisting component of lactic acidosis. These are the extreme conditions that justify consideration of sodium bicarbonate (NaHCO3) infusion. The concern involves the serum potassium, which could shift intracellularly with a rapid rise in pH. If present, hyperka-lemia would be an overall benefit, but if the ECG is indeterminate or hypokalemia already exists, a further decline in serum potassium would be disastrous. Thus, administration of sodium bicarbonate should be done slowly with caution. Bolus therapy with 100 mEq NaHCO3 can also cause a transient hyperosmolality. with a potentially deleterious water shift in the brain. Sodium bicarbonate is more safely delivered isotonically as 100 mEq or 100 mL added to 1 L of 0.45% NS. The addition of the sodium would make this almost an isotonic solution, and delivery of bicarbonate ions in the large volume would preclude any sudden pH shifts.

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