Sodium bicarbonate therapy during out-of-hospital cardiac arrest: Is presenting rhythm the key to benefit?

Abstract

Sodium bicarbonate was introduced into the management of cardiac arrest in the 1970s with the intent of correcting associated metabolic acidosis to help restore pH balance. [1] JAMA. 1974; 227: S852-S860 Google Scholar Efficacy and safety concerns associated with sodium bicarbonate therapy in the 1980s including paradoxical intracellular acidosis, hypernatremia, volume overload, and systemic alkalosis subsequently led to a reassessment of its use and over time, successive international resuscitation guidelines have deemphasized its use. 2 Velissaris D. Karamouzos V. Pierrakos C. Koniari I. Apostolopoulou C. Karanikolas M. Use of Sodium Bicarbonate in Cardiac Arrest: Current Guidelines and Literature Review. J Clin Med Res. 2016; 8: 277-283 Google Scholar , 3 Panchal A.R. Bartos J.A. Cabañas J.G. et al. Adult Basic and Advanced Life Support Writing Group. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020; 142: S366-S468 Google Scholar , 4 Perkins G.D. Graesner J.T. Semeraro F. Collaborators E.R.C.G. Guidelines E.R.C. et al. Executive summary. Resuscitation. 2021; 2021: 1-60 Google Scholar Current AHA guidelines recommend against the routine administration of sodium bicarbonate for undifferentiated cardiac arrest but allow for its use in cases where the cause of the arrest is thought to be secondary to sodium channel blocker toxicity (e.g., tricyclic antidepressants, diphenhydramine) and as adjunctive therapy in suspected hyperkalemia. [3] Panchal A.R. Bartos J.A. Cabañas J.G. et al. Adult Basic and Advanced Life Support Writing Group. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020; 142: S366-S468 Google Scholar The ERC guidelines also suggest that sodium bicarbonate may be considered in a prolonged unresponsive resuscitation with effective ventilation to potentially reverse intracardiac acidosis. [4] Perkins G.D. Graesner J.T. Semeraro F. Collaborators E.R.C.G. Guidelines E.R.C. et al. Executive summary. Resuscitation. 2021; 2021: 1-60 Google Scholar Guideline recommendations on bicarbonate therapy continue to be discussed and challenged. 2 Velissaris D. Karamouzos V. Pierrakos C. Koniari I. Apostolopoulou C. Karanikolas M. Use of Sodium Bicarbonate in Cardiac Arrest: Current Guidelines and Literature Review. J Clin Med Res. 2016; 8: 277-283 Google Scholar , 5 Dybvik T. Strand T. Steen P.A. Buffer therapy during out-of-hospital cardiopulmonary resuscitation. Resuscitation. 1995; 29: 89-95 Google Scholar , 6 Ahn S. Kim Y.J. Sohn C.H. et al. Sodium bicarbonate on severe metabolic acidosis during prolonged cardiopulmonary resuscitation: a double-blind, randomized, placebo-controlled pilot study. J Thorac Dis. 2018; 10: 2295-2302 Google Scholar