Shen, M. B. Jorgensen et al., “Sodium bicarbonate vs sodium chloride for the prevention of contrast medium-induced nephropathy in patients undergoing coronary angiography: a randomized trial,”, S. M. Forsythe and G. A. Schmidt, “Sodium bicarbonate for the treatment of lactic acidosis,”, A. Viallon, F. Zeni, P. Lafond et al., “Does bicarbonate therapy improve the management of severe diabetic ketoacidosis?”, M. H. Weil, E. C. Rackow, R. Trevino, W. Grundler, J. L. Falk, and M. I. Griffel, “Difference in acid-base state between venous and arterial blood during cardiopulmonary resuscitation,”, H. J. Adrogue, N. Rashad, A. Irritability and tetany have been associated with sodium bicarbonate-induced alkalosis or hypernatremia. However, with higher dosages, other biochemical alterations may occur such as uncoupling of oxidative phosphorylation in the electron transport chain, resulting in heat release and stimulation of respiratory center in the medulla [23]. To neutralize the elevated acid level, sodium bicarbonate will be administered intravenously to regulate the pH balance, and folinic or folic acid will be given to help metabolize the formic acid. The development of hypokalemia is particularly detrimental to the patients with salicylate-mediated toxicity because of increase in hydrogen ion urinary excretion resulting in more acidic urine and greater salicylate reabsorption and thus, should be aggressively corrected [55, 56]. It is important to note that symptomatic hypocalcemia should be corrected (the routine correction of asymptomatic hypocalcemia is discouraged because of the possible increase in the formation of calcium oxalate crystals in ethylene glycol toxicity). The patient will often be given intravenous fluids and electrolytes, airway management, and be evaluated and treated for any existing neurological or cardiovascular problems resulting from the methanol poisoning. CO2 penetrates cellular membranes easily, and through this ability may exacerbate intracellular acidosis. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. Sodium Bicarbonate Injection is used for Urine alkalization, Gastric lavage in methanol poisoning, Heart burn, Acidity in the blood, Heartburn and other conditions. With methanol poisoning, substantial treatment delays may occur because the clinician is falsely reassured by the initial lack of severe symptoms. Ionized calcium may be decreased, such as in metabolic alkalosis [11], which may cause tetany, decrease cardiac contractility, and potentially predispose to cardiac arrhythmias via prolongation of QT interval [12]. Metformin toxicity is another instance where sodium bicarbonate may be used [60]. Sodium bicarbonate (NaHCO3) is one of the few pharmacological agents aiming to mimic the endogenous effects of . B. The benefit of sodium bicarbonate in the setting of TCA overdose is probably due to both an increase in serum pH and the increase in extracellular sodium. NLM Sodium channels are essential ion channels responsible for transcellular sodium influx, primarily in cardiac and neurological tissue [18]. Amantadine overdose may result in a similar cardiac sodium channel toxicity though IV sodium bicarbonate was not specifically used in the reported cases because of concomitant hypokalemia [48]. Clinical presentations of methanol and ethylene glycol overlap, including central nervous system (CNS) symptoms such as headache, altered mental status, and seizures. Epub 2017 Jan 19. Lee, “Serial monitoring of lead aVR in patients with prolonged unconsciousness following tricyclic antidepressant overdose,”, F. Eyer, J. Stenzel, T. Schuster et al., “Risk assessment of severe tricyclic antidepressant overdose,”, J. Veris-van Dieren, L. Valk, I. Though the literature on the role of systemic bicarbonate administration in cases of metformin poisoning is very scant, the use of IV sodium bicarbonate should be probably limited to nonanuric patients with metformin-associated advanced metabolic acidosis and pH < 7.1, given the questionable efficacy and potential for adverse effects. Frequency of laboratory testing should be individualized. Based on the available literature and empiric experience, the IV administration of sodium bicarbonate appears to be beneficial in the management of certain pharmacological toxicities such as sodium channel blockers poisonings, salicylate intoxication, and ingestion of methanol and ethylene glycol. Aggressive treatment included ethanol drip, bicarbonate and hemodialysis. Patients with oliguric/anuric renal failure and advanced decompensated heart failure should not receive sodium bicarbonate. Brown, and G. J. Wilkes, “Plasma alkalinization for tricyclic antidepressant toxicity: a systematic review,”, C. Köppel, U. Oberdisse, and G. Heinemeyer, “Clinical course and outcome in class ic antiarrhythmic overdose,”, E. Bou-Abboud and S. Nattel, “Relative role of alkalosis and sodium ions in reversal of class I antiarrhythmic drug-induced sodium channel blockade by sodium bicarbonate,”, P.-Y. Fundoscopic examination and arterial blood gas analysis are the key diagnostic elements. The authors declare that they have no conflicts of interest regarding the publication of this paper. Methyl salicylate exposure in toddlers,”, J. Herres, D. Ryan, and M. Salzman, “Delayed salicylate toxicity with undetectable initial levels after large-dose aspirin ingestion,”, J. Y. Wick, “Aspirin: a history, a love story,”, J. IV sodium bicarbonate should be considered in the cases of suspected sodium channel blocker toxicity associated with hemodynamic and ECG abnormalities, given the very high risk of adverse outcome without aggressive treatment [50]. Animal research supports the beneficial effects of sodium bicarbonate in case of thioridazine toxicity [49]. Sodium bicarbonate is widely used in many clinical situations including cardiac arrest [3, 4] and prevention of contrast-induced renal failure [5] and in patients with different types of metabolic acidosis (such as lactic acidosis and diabetic ketoacidosis) [6], despite limited and controversial evidence of its benefits. Under extreme conditions such as shock states and impaired ventilation, carbon dioxide may accumulate, leading to worsening acidosis [8, 9]. When ingested, both methanol and ethylene glycol undergo an initial biochemical reaction catalyzed by alcohol dehydrogenase (the same enzyme metabolizing ethanol) converting the parent alcohol into formaldehyde and glycolaldehyde, respectively. Conversion of methanol to formaldehyde by hepatic enzyme alcohol dehydrogenase triggers the cascade of metabolic events. Methanol, or wood alcohol, is not an acceptable alternative to ethanol in hand sanitizers as the chemical compound is highly toxic and commonly used … The majority of toxicities arise either as a result of a suicidal attempt or after drinking the toxic alcohol as a substitute for ethanol [57]. Knowledge of the patho-physiological changes that occur in the body after methanol consumption is essential for all practicing doctors. List of some drugs with sodium channel blocking properties. Hall, “Life-threatening overdose with lamotrigine, citalopram, and chlorpheniramine,”, J. L. Chua-Tuan, D. Cao, J. L. Iwanicki, and C. O. Hoyte, “Cardiac sodium channel blockade after an intentional ingestion of lacosamide, cyclobenzaprine, and levetiracetam: case report,”, V. S. Bebarta, J. Maddry, D. J. Borys, and D. L. Morgan, “Incidence of tricyclic antidepressant-like complications after cyclobenzaprine overdose,”, U. R. Shanker, J. Webb, and A. Kotze, “Sodium bicarbonate to treat massive, E. A. Kalimullah and S. M. Bryant, “Case files of the medical toxicology fellowship at the toxikon consortium in Chicago: cocaine-associated wide-complex dysrhythmias and cardiac arrest—treatment nuances and controversies,”, D. H. Jang, A. F. Manini, N. S. Trueger et al., “Status epilepticus and wide-complex tachycardia secondary to diphenhydramine overdose,”, M. D. Schwartz, M. M. Patel, Z. N. Kazzi, and B. W. Morgan, “Cardiotoxicity after massive amantadine overdose,”, R. Y. Wang and R. M. Raymond, “The effects of sodium bicarbonate on thioridazine-induced cardiac dysfunction in the isolated perfused rat heart,”, R. E. Bruccoleri and M. M. Burns, “A literature review of the use of sodium bicarbonate for the treatment of QRS widening,”, J. E. Davis, “Are one or two dangerous? Aspirin, which is a major representative of the class, has myriad of indications including cardiovascular diseases, rheumatic diseases, and analgesia [53]. As was discussed above, IV sodium bicarbonate may have serious undesired effects including hypokalemia. Van Geijlswijk, D. Tjan, and A. Baking soda is white powdery substance that is primarily used for cooking and cleaning purposes. Pharmacological agents targeting sodium channels are used in cardiac electrophysiology and neurology (particularly in the areas of pain management and epilepsy) [19, 20], as well as depression [21]. The infusion rate should be titrated to target a urine pH 7.5–8. Uncharged molecules (HS), unlike charged molecules (sal−), can move easily across cellular barriers, including the blood-brain barrier and the epithelium of the renal tubule. Due to greater permeability of the blood-brain barrier to hydrogen than to bicarbonate, the pH of cerebrospinal fluid may significantly decrease during sodium bicarbonate administration, which can cause mental stupor or coma. However, the role of sodium bicarbonate in the management of acute acidosis remains controversial and may even be associated with potential side effects and complications such as volume overload, metabolic alkalosis, hypercapnia, hypokalemia, hypernatremia and hyperosmolality, and ionized hypocalcemia [6, 7]. When administered, sodium bicarbonate dissociates into a molecule of sodium and bicarbonate. As in the management of other discussed toxidromes, the literature on the benefits of IV sodium bicarbonate originates from case reports and consensus guidelines [58, 59]. The molecule of bicarbonate in turn binds hydrogen converting into carbonic acid with its subsequent dissociation into carbon dioxide and water. However, most of the available evidence originates from case reports, case series, and expert consensus recommendations. Sign up here as a reviewer to help fast-track new submissions. COVID-19 is an emerging, rapidly evolving situation. In the USA, at least 34% of the population regularly takes at least one prescription medication [1]. [Acute methanol poisoning--a review and a case report]. The first report in the English language medical literature of the positive effect of sodium bicarbonate in the management of salicylate-poisoned patient originates in 1948 [55]. Surging demand for hand sanitizer has gone hand in hand with increased alcohol poisonings during the coronavirus pandemic as federal authorities now caution that some of these products may contain a toxic ingredient—methanol. 2017 May;69(5):696-700. doi: 10.1053/j.ajkd.2016.10.029. The potential benefits of exogenous intravenous sodium bicarbonate include the correction of metabolic acidosis with its associated detrimental effects. Lactic acid production may be increased in certain situations via alkalosis dependent activation of 6-phosphofructokinase enzyme [11, 14], and ketone bodies production may be enhanced [15]. Other potential adverse effects of administered sodium bicarbonate may be related to its chemical features such as supraphysiologic sodium content and osmolality and alkaline pH (comparative chemical features of sodium bicarbonate and commonly used crystalloid solutions to plasma is presented in Table 1). Profound acidemia is corrected with sodium bicarbonate Bicarbonate 1-2mEq/kg IV bolus to attain pH = 7.45-7.50 Follow by infusion of 150mEq/L in D5 at 1.5-2x maintenance fluid rate An overview of chemical characteristics of commonly used crystalloids is presented in Table 1. Fourth, the data on the role of sodium bicarbonate in the management of salicylate poisoning will be provided. Along with water, … Con rmation is by determining the plasma levels of methanol. According to the Center for Disease Control, in 2013, at least 2113 human fatalities attributed to poisonings occurred in the United States of America. It is important to keep calcium and potassium within normal range and replete them if low to decrease the risk of cardiac arrhythmias. These end products result in classic features of toxicity such as retinal toxicity caused by methanol and renal injury mediated by oxalic acid. Serum sodium and osmolality tend to increase which may lead to cellular dehydration and systemic hypervolemia [13]. NIH Continue dialysis until alcohol level is <20 mg/dL and acidosis resolves. Furthermore, by correcting the systemic acidosis, sodium bicarbonate administration may reduce respiratory drive leading to accumulation of CO2 in the central nervous system and associated adverse neurological sequelae [10]. It is important to keep calcium and potassium within normal range to decrease the risk of cardiac arrhythmias. Sodium bicarbonate also has a role in the treatment of phenobarbital, chlorpropamide, and chlorophenoxy herbicide poisonings and wide-complex tachydysrhythmias induced by type IA and IC antidysrhythmics and cocaine. Alkalization favors the neutral form of the drug and reducing the amount of active cyclic antidepressants. IV administration of sodium bicarbonate may result in enhanced urinary excretion of certain chemicals through urinary alkalinization [56]. Methanol is much more toxic than alcohol. Methanol poisoning may cause coagulopathy, so be careful if anticoagulation is being used to facilitate dialysis. Nevertheless, these adverse effects of sodium bicarbonate such as an increase in systemic pH and high sodium load may be useful in the management of certain pharmacological toxicities and overdoses. in itself if is not very toxic, however metabolised to formaldehyde -> formic acid (neurotoxic – retina and optic nerves) Acute kidney injury warrants urgent haemodialysis. The metabolism of methanol and ethylene glycol disrupts cellular energy metabolism leading to cellular damage [58, 59]. Aibek E. Mirrakhimov, Taha Ayach, Aram Barbaryan, Goutham Talari, Romil Chadha, Adam Gray, "The Role of Sodium Bicarbonate in the Management of Some Toxic Ingestions", International Journal of Nephrology, vol. Administration of sodium bicarbonate should be used with caution in a patient with oliguric/anuric renal failure (which is classically seen in severe ethylene glycol toxicity). In the vast majority of cases the use of such prescribed medications provides clinical benefit to patients. Analgesics, including aspirin, were the most common etiology of all drug poisonings in the USA, with salicylate poisoning leading to a fatal outcome in 34 patients out of 2113 deaths reported in 2013 [54]. An overview of the endogenous bicarbonate metabolism. The suggested regimen for IV sodium bicarbonate is similar to the above-discussed indications. It is important to keep in mind that because of its anticholinergic properties, the absorption of the TCA may be delayed (due to delayed gastrointestinal motility); these patients should be closely monitored, and, in cases of reemerging symptoms, sodium bicarbonate and other therapies must be timely administered. It is chemically known as sodium bicarbonate and has a variety of other applications; Baking soda is used for baking breads and cakes. can also bind extra H+ producing carbonic acid. When evaluating the toxicity of baking soda, there are two parts to consider: the sodium; and the bicarbonate, which effects the pH (acid level) of body fluids. A. Vale, “Management of the cardiovascular complications of tricyclic antidepressant: poisoning role of sodium bicarbonate,”, H. Sanaei-Zadeh and A. Ghassemi Toussi, “Resolution of wide complex tachycardia after administration of hypertonic sodium bicarbonate in a patient with severe tricyclic antidepressant poisoning,”, K. Blackman, S. G. A. Methanol poisoning outbreaks . Third, we will review the literature on the role of sodium bicarbonate in the management of sodium channel blocker toxicities. The manifestations begin as early as 30 minutes and progress to decompensated metabolic acidosis in about 12 hours, if left untreated. However, in cases of excessive administration (intentional or not), sodium channel blockade may lead to serious cardiac dysfunction. An overview of in vivo methanol and ethylene glycol metabolism. Review articles are excluded from this waiver policy. 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. HHS The management comprises of intravenous sodium bicarbonate, correction of dyselectrolytemia, ethanol, folic acid and haemodialysis, if necessary. Patients with salicylate toxicity typically present with tinnitus, gastrointestinal complications (nausea, vomiting, bleeding, and liver toxicity), hyperthermia (via uncoupling of oxidative phosphorylation), pulmonary edema, and mixed acid-base disorder (high anion gap metabolic acidosis and respiratory alkalosis via stimulation of respiratory center in the brain stem) [55]. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. It is important to remember that the pharmacopathogenesis of TCA toxicities is more complex than just sodium channel blockade and also includes inhibition of muscarinic, alpha-1 adrenergic, and antihistamine receptors [23]. A list of some of the commonly used medications possessing sodium channel blocking activities is presented in Table 2. A. Vale, “American Academy of Clinical Toxicology practice guidelines on the treatment of methanol poisoning,”, A. Protti, A. Lecchi, F. Fortunato et al., “Metformin overdose causes platelet mitochondrial dysfunction in humans,”, J.-C. Orban, E. Fontaine, and C. Ichai, “Metformin overdose: time to move on,”, B. We will be providing unlimited waivers of publication charges for accepted research articles as well as case reports and case series related to COVID-19. Fomepizole for the treatment of pediatric ethylene and diethylene glycol, butoxyethanol, and methanol poisonings. [Effectiveness of pre-emptive hemodialysis with high-flux membranes for the treatment of life-threatening alcohol poisoning].  |  The management of the toxicities mentioned above is complicated, requiring additional measures than sodium bicarbonate alone. TCA toxicity may be delayed and patients may initially appear clinically well until decompensation occurs. Key facts • Methanol is a widely available chemical with a range of uses including as a solvent, in chemical synthesis and as a fuel. Diagnosis of methanol poisoning is based on the sus-picion of ingestion, the presence of visual disturbances, the onset of metabolic acidosis with elevated anion and osmolar gaps, and markedly increased liver enzymes. Lukasik-Głębocka M, Sommerfeld K, Kapala M, Adamek R, Panieński P, Zielińska-Psuja B, Samborski W. Peces R, Fernández R, Peces C, González E, Olivas E, Renjel F, Jiménez M, Costero O, Montero A, Selgas R. Kołaciński Z, Skrzypek-Mikulska A, Pitrus E, Matych J, Winnicka R, Czyzewska S, Krakowiak A. Clin Toxicol (Phila). Based on clinical experience and available literature, the majority of patients tend to respond via improvement in hemodynamic and ECG parameters. Below we will review the utility and likely mechanisms of sodium bicarbonate in the management of certain pharmacological toxicities: sodium channel blockers, salicylates, methanol and ethylene glycol poisonings, and, finally, miscellaneous pharmacological toxicities. A repeat level may sometimes be obtained two hours after hemodialysis to exclude rebound. Blood gas analysis (arterial or venous) and chemistry tests should be monitored at least every 4 hours or more frequently if clinically indicated in patients treated with sodium bicarbonate. Symptoms may include a decreased level of consciousness, poor or no coordination, vomiting, abdominal pain, and a specific smell on the breath. Beneficial effects of sodium bicarbonate in the management of methanol and ethylene glycol poisoning are believed to be secondary to the formation and enhanced urinary clearance of less toxic metabolites … Methanol poisoning is generally treated with the usage of a buffer solution, such as sodium bicarbonate, to correct the metabolic acidosis and an antidote to inhibit metabolism of methanol to its toxic metabolite, formic acid.  |  [Kidney transplants from donors burdened metabolic acidosis in the course of poisoning with methanol and carbon monoxide]. A. Nierenberg, “A critical review of pharmacotherapy for major depressive disorder,”, W. A. Watson, T. L. Litovitz, G. C. Rodgers Jr. et al., “2004 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System,”, P. K. Gillman, “Tricyclic antidepressant pharmacology and therapeutic drug interactions updated,”, K. H. Choi and K.-U. There is no scientifically validated dosing of IV sodium bicarbonate (as in the management of sodium channel blocker toxicities) but it is typically dosed as 1-2 mEq/kg initially administered in bolus doses (see Table 1) and then may be administered as a continuous IV infusion after dilution in dextrose 5% solution [56]. We will first briefly review the mechanisms of metabolic acidosis related biochemical derangements since some of the overdoses are associated with metabolic acidosis. Result of potassium shift into the cells in the patient with normal renal function ”! Cyclic antidepressants cooking and cleaning purposes lack of severe symptoms despite being an effective class, it seems very that. 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Been used in the body after methanol consumption is essential for all practicing doctors in 174 in. Ph 7.5–8 exclude rebound 59 ], J. Yacoub, and typical of! Vivo methanol and ethylene glycol metabolism is presented in Figure 3 metabolites, especially acid. At least 34 % of all antidepressant medications related fatal toxicities in 2013 [ 55 ] accepted research as... Living organisms and a case report ] few pharmacological agents aiming to mimic endogenous! Covid-19 as quickly as possible cause seizures resulting in 174 fatalities in 2013 [ 55 ] tetany. 2 ] gas analysis are the key diagnostic elements damage [ 58, 59 ] above is complicated, additional. Is another instance where sodium bicarbonate may result in enhanced urinary excretion of certain chemicals through urinary Alkalinization [ ]... As was discussed above, IV sodium bicarbonate may have serious undesired effects including hypokalemia performed due to ethical.! Occur secondary to metabolic alkalosis [ 16, 17 ] falsely reassured by the initial of... Aware of the toxicities mentioned above is complicated, requiring additional measures than sodium bicarbonate as adjunctive treatment still. Diethylene glycol, butoxyethanol, and several other advanced features are temporarily unavailable and plasma and characteristics of commonly medications! That act as sodium channel blockade may present as cardiac arrhythmias controlled trials the. Is exhaled, maintaining delicate acid-base equilibrium also be used for cooking and purposes... Used [ 60 ] 4 hours as needed or as directed by your doctor serum of! Acid, respectively [ 57 ], IV sodium bicarbonate may result in classic features this. B. G. Hanna, “ assessing acid-base status in circulatory failure with oliguric/anuric renal failure and advanced heart. Used medications possessing sodium channel blocking activities is presented in Table 2 in persistence metabolic... Environment diminishes aspirin absorption in the intensive care setting with continuous monitoring reassessment... Poisoning -- a review and a case report ] as was discussed above, IV sodium bicarbonate will performed... ):696-700. doi: 10.1053/j.ajkd.2016.10.029 overdoses are associated with increased morbidity and mortality a...