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sodium bicarbonate injection
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----------Sodium Bicarbonate Injection, USP
Sodium Bicarbonate Injection, USP, is a sterile, aqueous, pyrogen-free preparation of sodium bicarbonate (NaHCO3). It is available in three hypertonic solutions with concentrations expressed as follows:
The pH of the above solutions may have been adjusted by means of added carbon dioxide and is approximately 7.8 (USP pH limits: between 7.0 and 8.5).
These preparations contain no preservatives and are intended only as single dose vials; once the units are assembled and used, any remaining portion of the solution must be discarded with the integral units.
Sodium bicarbonate therapy increases plasma bicarbonate, buffers excess hydrogen ion concentration, raises blood pH and reverses the clinical manifestations of metabolic acidosis. It is also useful in patients who require alkalinization of body fluids for other reasons.
Sodium bicarbonate in water dissociates to provide sodium (Na+) and bicarbonate (HC03-) ions. Sodium is the principal cation of the extracellular fluid. Bicarbonate is a normal constituent of body fluids and the normal plasma level ranges from 24 to 31 mEq/L. Plasma concentration is regulated by the kidney. Bicarbonate anion, at a proper concentration of hydrogen ion (H+), may be converted to carbonic acid (H2CO3), then to its volatile form, carbon dioxide (CO2) excreted by the lung. Normally, a ratio of 1:20 (carbonic acid:bicarbonate) is present in the extracellular fluid. In a healthy adult with normal kidney function, practically all the glomerular filtered bicarbonate ion is reabsorbed; less than 1% is excreted in the urine.
INDICATIONS AND USAGE
Sodium Bicarbonate Injection, USP, is indicated in the treatment of metabolic acidosis which may occur in severe renal disease, uncontrolled diabetes, circulatory insufficiency due to shock or severe dehydration, extracorporeal circulation of blood, cardiac arrest and severe primary lactic acidosis. Sodium bicarbonate is further indicated in the treatment of certain drug intoxications, including barbiturates (where dissociation of the barbiturate-protein complex is desired), in poisoning by salicylates or methyl alcohol, and in hemolytic reactions requiring alkalinization of the urine to diminish nephrotoxicity of blood pigments. Urinary alkalinization is also used in methotrexate therapy to prevent nephrotoxicity. Sodium bicarbonate also is indicated in severe diarrhea, which is often accompanied by a significant loss of bicarbonate.
Treatment of metabolic acidosis should, if possible, be superimposed on measures designed to control the basic cause of the acidosis - e.g., insulin in uncomplicated diabetes, blood volume restoration in shock. But since an appreciable time interval may elapse before all of the ancillary effects are brought about, bicarbonate therapy is indicated to minimize risks inherent to the acidosis itself.
Vigorous bicarbonate therapy is required in any form of metabolic acidosis where a rapid increase in plasma total CO2 content is crucial - e.g., cardiac arrest, circulatory insufficiency due to shock or severe dehydration, and in severe primary lactic acidosis or severe diabetic acidosis.
Sodium bicarbonate is contraindicated in patients: losing chloride by vomiting or from continuous gastrointestinal suction; receiving diuretics known to produce a hypochloremic alkalosis; with metabolic and respiratory alkalosis; with hypocalcemia in which alkalosis may produce tetany.
In neonates and children under two years of age, rapid injection (10 mL/min) of hypertonic sodium bicarbonate solutions may produce hypernatremia, a decrease in cerebrospinal fluid pressure and possible intracranial hemorrhage. The rate of administration in such patients should therefore be limited to no more than 8 mEq / kg / day. A 4.2% solution may be preferred for such slow administration.
The risk of rapid infusion may be necessary because of the potential for fatality due to acidosis. Sodium bicarbonate solutions are usually hypertonic and may produce an undesirable rise in plasma sodium concentration in the process of correction of metabolic acidosis. In cardiac arrest, however, the risks from acidosis exceed those of hypernatremia, which can be treated in the next phase of the therapeutic regimen.
The risk of dilutional states is inversely proportional to the electrolyte concentrations of administered parenteral solutions. The risk of solute overload causing congested states with peripheral and pulmonary edema is directly proportional to the electrolyte concentrations of such solutions.
Overdosage and alkalosis should be avoided by giving repeated small doses and monitoring appropriate laboratory tests.
The solutions of hypertonic NaHCO3 may cause vascular irritation or sloughing if given extravascularly. Avoid scalp vein use with hypertonic solutions.
In the process of substantially correcting the low total CO2 content and blood pH with bicarbonate therapy, the risks of overdosage and alkalosis should be avoided.
Repeated fractional doses and periodic monitoring by suitable laboratory test, e.g., arterial blood gases, are therefore recommended to minimize the possibility of overdosage. The actual total amount of sodium bicarbonate administered is governed by the successive clinical responses of the patient to each repeated fractional dose. Once the severe symptoms have been controlled, the size of each fractional dose and the frequency of administration should be decreased in order to gradually restore the normal bicarbonate levels.
Since sodium accompanies bicarbonate, caution should be observed in patients with congestive heart failure or other edematous or sodium-retaining states, as well as in patients with oliguria or anuria. Each mL of the following concentrations of sodium bicarbonate injection contains the following corresponding amounts of sodium (Na+):
Potassium depletion may predispose to metabolic alkalosis, and coexistent hypocalcemia may be associated with carpopedal spasm as the plasma pH rises. These dangers can be minimized if such electrolyte imbalances are treated prior to or concomitantly with bicarbonate.
Excessive administration of sodium bicarbonate can cause an intracellular shift of potassium, inducing hypokalemia and predisposing the patient to cardiac arrhythmias.
Patients losing chloride by vomiting or gastrointestinal suction are more susceptible to developing severe alkalosis if given alkalinizing agents.
Both pulmonary ventilation and perfusion must be adequately supported whenever respiratory acidosis is concomitant with metabolic acidosis in order to get rid of excess CO2.
Parenteral Fluid Compatibility
The addition of sodium bicarbonate to parenteral solutions containing calcium should be avoided, except where compatibility has been previously established. Precipitation or haze may result from sodium bicarbonate-calcium admixtures. Should this occur, such a solution should be immediately discarded.
Caution should be observed when giving parenteral fluids, especially those containing sodium ions, to patients receiving corticosteroids or corticotropin.
Increased half-lives and duration of action of quinidine, amphetamines, ephedrine, and pseudoephedrine may occur with urinary alkalinization by sodium bicarbonate.
Sodium bicarbonate, by producing an alkaline urine, increases the renal clearance of tetracyclines, especially doxycycline.
USAGE IN PREGNANCY
Pregnancy Category C
Animal reproduction studies have not been conducted with sodium bicarbonate. It is also not known whether sodium bicarbonate can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Sodium bicarbonate should be given to a pregnant woman only if clearly needed.
Alkalosis and / or hypokalemia may ensue as a result of overdosage or over-correction of the bicarbonate deficit. Severe alkalosis may be accompanied by hyperirritability or tetany.
Extravasation of I.V. hypertonic solutions of sodium bicarbonate may cause chemical cellulitus, with tissue necrosis, ulceration or sloughing at the site of infiltration. Prompt elevation of the part, warmth and local injection of lidocaine or hyaluronidase are recommended to prevent sloughing.
Excessive or too rapid administration may produce alkalosis. Severe alkalosis may be accompanied by hyperirritability or tetany. (See ADVERSE REACTIONS).
Sodium bicarbonate should be discontinued and the symptoms of alkalosis controlled by rebreathing expired air from a paper bag or rebreathing mask or, if more severe, by parenteral injections of calcium gluconate. Severe alkalosis may be corrected by I.V. infusion of 2.14% ammonium chloride solution, except in patients with hepatic disease, in whom ammonia use is contraindicated. Sodium chloride (0.9%) I.V. or potassium chloride may be indicated if there is hypokalemia. Calcium gluconate is administered to control tetany.
DOSAGE AND ADMINISTRATION
Please note that the optional STICK-GARD® Safety Needle, featured with stock number 2052 is interchangeable with a standard needle.
Sodium Bicarbonate Injection, USP is administered by the intravenous route, preferably into a large vein. Suitable concentrations range from 1.4% (isotonic) to 8.4% (undiluted), depending upon the clinical condition and requirement of the patient. The MIN-I-JET® Luer-Lock disposable syringe features STICK-GARD®, a recessed needle enclosed in a protective plastic sheath. The Stick-Gard® Safety Needle is pre-attached to the Luer-Lock of the syringe injector. The Stick-Gard® Safety Needle is intended for use onto the Y-site of an I.V. set or a heparin lock injection site. Since the Stick-Gard® Safety Needle cannot be used for direct injection (I.V. or I.M.) or for entering glass I.V. bottles and certain plastic I.V. bags, the Stick-Gard® Safety Needle should be replaced with a suitable needle when the above modes of administration are recommended or appropriate.
The need for Sodium Bicarbonate Injection is dependent upon the pH of the serum and the clinical symptoms of the patient as well as the base (bicarbonate) deficit. However, the dose of sodium bicarbonate can be based primarily upon the plasma deficit. This is the difference between the average normal bicarbonate of the plasma (27 mEq/ L) and the value determined for the patient.
If plasma bicarbonate of the patient with metabolic acidosis is unknown, a safe average of sodium bicarbonate is 5 mEq (420 mg) per kilogram of body weight. If the patient has severe metabolic acidosis, bicarbonate solutions containing 90–180 mEq/L (approximately 7.5 – 15 g) may be given at rates of 1–1.5 liters during the first hour. The concentration of bicarbonate solutions used for further management of the patient may be adjusted to the needs of the patient.
Usual adult dosage
Systemic alkalizer —
Urinary alkalizer — Intravenous, 2 to 5 mEq per kg of body weight, administered over a period of 4 to 8 hours.
Usual pediatric dosage
Systemic alkalizer —
Urinary alkalizer — See Usual adult dosage.
In cardiac arrest
Sodium bicarbonate should be administered according to the result of arterial blood pH and PaC02 and calculation of base deficit. Caution should be observed where rapid infusion of large quantities of bicarbonate is indicated. Bicarbonate solutions are hypertonic and may produce an undesirable rise in plasma sodium concentration. In cardiac arrest however, the risks from acidosis exceed those of hypernatremia.
In infants, (up to two years of age), the 4.2% solution is recommended for intravenous administration at a rate not to exceed 8 mEq / kg/ day. This dosage is recommended in neonates to guard against the possibility of producing hypernatremia, decreasing cerebrospinal fluid pressure and inducing intracranial hemorrhage.
If base deficit is known, a calculated dose of 0.3 × kg × base deficit is given. If only 8.4% sodium bicarbonate is available, it may be diluted 1:1 with 5% dextrose in water before administration.
In less urgent forms of metabolic acidosis
Sodium Bicarbonate Injection, USP, may be added to other intravenous fluids. Desired dilutions may be prepared using sterile water, sodium chloride (0.9%), dextrose 5%, or other standard electrolyte solutions as diluent. The amount of bicarbonate to be given to older children and adults over a four-to eight-hour period depends upon the severity of the acidosis as judged by the lowering of total C02 content, blood pH and clinical condition of the patient. Bicarbonate therapy should always be planned in a stepwise fashion since the degree of response from a given dose is not precisely predicable. Initially an infusion of 2 to 5 mEq per kg body weight over a period of 4 to 8 hours will produce a measureable improvement in the abnormal acid-base status of the blood.
Alternatively, estimates of the initial dose of sodium bicarbonate may be based on the following equation:
One-half of this calculated estimate is given. The next step of therapy is dependent upon the clinical response of the patient. If severe symptoms have abated, the frequency of administration and dose may be reduced.
In general, it is unwise to attempt full correction of a low total CO2 content during the first 24 hours of therapy, since this may be accompanied by an unrecognized alkalosis because of a delay in the readjustment of ventilation to normal. Owing to this lag, the achievement of total CO2 content of about 20 mEq/ L at the end of the first day of therapy will usually be associated with a normal blood pH. Further modification of the acidosis to completely normal values usually occurs in the presence of normal kidney function when and if the cause of the acidosis can be controlled. Values for total CO2 which are brought to normal or above normal within the first day of therapy are very likely to be associated with grossly alkaline values for blood pH, with ensuing undesirable side effects.
NOTE: Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.
Do not use the injection if it contains a precipitate.
Sodium Bicarbonate Injection, USP
In unit-use packages containing a MIN-I-JET® disposable syringe.
In unit-use packages containing a MIN-I-JET® disposable syringe with Luer-Lock and optional STICK-GARD® Safety Needle.
Twenty-five unit-use packages per carton.
Manufactured under U.S. Pat No. 4,834,716, Reissue No 33,617, STICK-GARD® Safety Needle.
In unit-use packages containing a Luer-Jet™ Luer-Lock Prefilled Syringe.
Ten unit-use packages per carton.
Syringe Assembly Directions
The MIN-I-JET® syringe with needle, illustrated below, is the basic unit upon which all the other syringe systems are built; slight adaptations and/ or additional auxillary parts create the other syringe systems. Assembly directions remain essentially the same.
USE ASEPTIC TECHNIQUE
Do not assemble until ready to use.
INTERNATIONAL MEDICATION SYSTEMS, LIMITED
PRINCIPAL DISPLAY PANEL - 4.2 g per 50 mL MIN-I-JET Prefilled Syringe label
FOR INTRAVENOUS USE
MIN-I-JET® 18 G. X 1 - 1 / 2" NEEDLE
PRINCIPAL DISPLAY PANEL - 4.2 g per 50 mL STICK-GARD Prefilled Syringe label
FOR INTRAVENOUS USE
STICK-GARD® PREFILLED SYRINGE
PRINCIPAL DISPLAY PANEL - 0.42 g per 10 mL LUER-LOCK Prefilled Syringe label
Luer-Lock Prefilled Syringe
FOR INTRAVENOUS USE
LUER-JET™ LUER-LOCK PREFILLED SYRINGE
PRINCIPAL DISPLAY PANEL - 4.2 g per 50 mL LUER-LOCK Prefilled Syringe label
Luer-Lock Prefilled Syringe
FOR INTRAVENOUS USE
LUER-JET™ LUER-LOCK PREFILLED SYRINGE
Revised: 09/2010 Amphastar Pharmaceuticals, Inc.
Reproduced with permission of U.S. National Library of Medicine
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