Abstract
BackgroundMetabolic Acidosis (MA) is a disturbance of the acid-base balance that can occur in preterm and critically ill term neonates due to different etiologies. Intravenous sodium bicarbonate (SB) has been traditionally used to correct such unbalance, despite the lack of evidence about its safety and efficacy. In literature, reported undesirable effects of treatment with SB in neonates include worsening of intracellular acidosis, impairment of myocardial function, cerebral blood flow fluctuations and intracranial hemorrhage. A national survey was conducted by the Neonatal Pharmacotherapy Study Group of the Italian Society of Neonatology with the aim to assess and describe attitudes and practices concerning the use of SB, particularly for the treatment of MA in Italian NICUs.MethodsA questionnaire regarding treatment of MA and SB prescription habits was sent to the directors of 120 Italian NICUs from June 2017 to March 2018.ResultsThe survey response rate was 97.5% (117/120 centers). Findings showed that in 55% of the surveyed NICUs (64/117 units) it is common practice to correct MA with intravenous SB. On the other hand, the remaining 45% of the units try to solve the metabolic disturbances adopting different approaches (improving perfusion, adjusting ventilation parameters or increasing blood volume). Moreover, to prevent the occurrence of MA, 37.6% of the NICUs (44/117) include buffer salts (lactate, acetate or both) in parenteral nutrition prescriptions. SB is also used as a treatment for other conditions, mainly pathologies with bicarbonate loss and tubular acidosis (respectively in 53.8 and 32.5% of the NICUs).ConclusionThis survey showed how SB is a commonly used treatment for MA in more than half of Italian NICUs, with indications and prescription criteria that significantly vary across centers. Based on current knowledge, it is reasonable to suggest that the management of neonatal MA should be firstly directed to identify the underlying disorders. Thus, the use of SB should be reserved only for selected cases, also considering the severity of SB adverse effects and the lack of evidence about its efficacy. Guidance for the management of MA is required to harmonize practices and reduce the use of potentially inappropriate and unsafe treatments.
Highlights
Metabolic Acidosis (MA) is a disturbance of the acid-base balance that can occur in preterm and critically ill term neonates due to different etiologies
Numerous reports showed significant negative effects due to sodium bicarbonate (SB) infusions, such as fluctuations in cerebral and cardiovascular hemodynamic [3, 4], increased rates of severe intraventricular hemorrhage (IVH) and mortality [5], SB is still used for treating MA in many neonatal intensive care units, as reported in a European survey conducted by Saenz P. et al in 2011
Neonatal intensive care unit (NICU) features Of the 117 investigated NICUs, the majority (83.8%) reside in perinatal centers that take care of more than 1000 neonates per year, 39% with 1000–2000 births/year and 45% with more than 2000 births/year
Summary
Metabolic Acidosis (MA) is a disturbance of the acid-base balance that can occur in preterm and critically ill term neonates due to different etiologies. Intravenous sodium bicarbonate (SB) has been traditionally used to correct such unbalance, despite the lack of evidence about its safety and efficacy. In literature, reported undesirable effects of treatment with SB in neonates include worsening of intracellular acidosis, impairment of myocardial function, cerebral blood flow fluctuations and intracranial hemorrhage. A national survey was conducted by the Neonatal Pharmacotherapy Study Group of the Italian Society of Neonatology with the aim to assess and describe attitudes and practices concerning the use of SB, for the treatment of MA in Italian NICUs. Despite being a common and largely debated issue, the management of neonatal metabolic acidosis (MA) still represents a challenge for clinicians, mainly due to the lack of evidence suggesting the most suitable and effective treatment. The historically established empiric correction of MA with intravenous sodium bicarbonate (SB) is a controversial and largely debated practice. The authors themselves commented that their study indicated the presence of a “gap between scientific evidence and clinical practice” [6]
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