Stop Giving Amps of Bicarb!

Chapter 1: What dafuq is in an amp of bicarb?

Take a look!

  • 50mL

  • 8.4% NaHCO3 -> 50mEq

  • The osmolarity of this solution is 2,000mOsm/L - twice that of 3% saline. < (click for emcrit)

Screen Shot 2020-11-05 at 7.56.02 PM.png

Chapter 2: Sodium bicarbonate doesn't just magically raise pH...

Remember this thing?

CO2 + H20 <=> H2CO3 <=> HCO3 + H

It's complicated. Bicarb binds to acid. Then it turns to CO2 and water, so you can breathe it out.

Basically if you're giving bicarb, you can only raise your pH as long as you can breathe off your CO2, increasing your RATE or VOLUME.

**This is particularly a problem in patients who are not in control of their breathing (vented), aren't breathing (arrest), or who have maximized the efficiency of their breathing (Kussmal breathing in DKA).**

That's right - you need to increase your minute ventilation to have a change in pH.

Here's Weingart's take.

Chapter 3: Sodium bicarb amps can cause harm!

FIRST:

One amp of bicarb is like giving 100cc of 3% hypertonic saline!! But as Josh Farkas points out, we typically have no hesitation giving "a couple of amps of bicarb."
This is a huge osmotic load which can lead to huge fluid shifts - prepare for that amp to increase intravascular fluid by 1/4 liter with every push. (Is this what you want to give to your renal failure pt? Your heart failure pt?)

SECOND:

You are worsening acidosis.
What? Huh? But I thought...
No. Stop. Shush. You're worsening acidosis.

Remember, you're increasing CO2 - whether you can breathe it off or not, this CO2 rises in but blood BUT ALSO rises in the tissues and may worsen acidosis in these tissues. < (click for litfl.com article)

THIRD:

Be ready to cause hypernatremia - expect a rise of 1mEq Na per amp of bicarb.

FOURTH:

Extravasation can cause tissue necrosis.

FIFTH:

CSF acidosis, hypocalcemia. Increased lactate. (Some may argue that's not a bad thing.)

If you do manage to fix the acidosis, you can overshoot and create an alkalosis and even screw up the oxygen dissociation curve (in a bad way).

Chapter 4: It just doesn't f&$%ing work
Cardiac arrest: it doesn't do anything. No increased survival. and AHA says it should not be given routinely.

Lactic acidosis: There's a whole section on UpToDate - there's minimal research for pH < 7.1 so you can consider it at that point... but otherwise, nah.

DKA: Take it from a nephrologist: In ketoacidosis, it is almost never necessary to give bicarbonate even though the patient is bicarbonate deficient unless renal function is permanently impaired. Therapy with fluids and electrolytes restores extracellular volume and renal blood flow, thus enhancing the renal excretion of acid and regenerating bicarbonate.

Hyperkalemia: Amps of bicarb, even in hyperK emergencies, have not been shown to lower potassium. Click that UpToDate link or listen to Scott Weingart talk about it on EMRAP.
Patients with hyperK should be started on isotonic bicarbonate drips for 4-6hours, a treatment that works better in acidotic patients.

CHAPTER 5: Soooo who gets bicarb?
AMPS:

  • Bicarb ampules in sodium channel blockade (like TCAs) are, as Dr. Bogoch said yesterday, the cornerstone of therapy

  • Bicarb ampules may be appropriate to alkalinize urine in certain toxicities

  • Seizing hyponatremic patients

DRIPS:

  • Appropriate in hyperK patients who can handle fluid

  • Appropriate in patients with AKI and pH < 7.2 (BICAR-ICU Trial)

  • May be appropriate for pH < 7.0 or 7.1, depending on who you talk to...

**If the pH is < 7.1 and you wanna give an amp of bicarb, there isn't enough data to say you're wrong. If it's a last-ditch effort, you might as well.

https://www.uptodate.com/contents/bicarbonate-therapy-in-lactic-acidosis?search=sodium%20bicarbonate&source=search_result&selectedTitle=3~148&usage_type=default&display_rank=2

Other references embedded in text.


Benzodiazepines

Benzo dosing and pharmacology has always been confusing to me. Here are some tidbits and pearls that stick with me:

Our very own fabulous Dr. Reuben Strayer’s IV to IM conversion of commonly utilized benzodiazepines. As he notes as well, conversions are more of an art than a science.

Our very own fabulous Dr. Reuben Strayer’s IV to IM conversion of commonly utilized benzodiazepines. As he notes as well, conversions are more of an art than a science.

PO conversion: 1 mg lorazepam = 10 mg diazepam = 25mg chlordiazepoxide (librium)

Short acting: midazolam, alprazolam/xanax

Medium acting: lorazepam, clonazepam/klonopin

Long acting: diazepam, librium  

IM midazolam, not IM lorazepam. Lorazepam’s intramuscular absorption is erratic/slower and it is longer acting than versed.  

Lorazepam is not a code white medication.  

10mg IM midazolam -> this patient goes to resus at least initially. This is an increasingly common dose for someone to receive by pre-hospital.  

Be wary of ETOH + benzos, these are extremely high risk patients.

The treatment of severe ETOH withdrawl/DT's requires probably an uncomfortable amount of benzos.

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Prescription Drug Prices

Prescription drug prices are highly variable and out of control in the United States. Often times, we will find ourselves telling a patient they should see their PMD and take all their medications, or we’ll be prescribing a medication for a newly diagnosed chronic condition. Whether or not our patients follow our advice is dependent on dozens of socioeconomic factors, but one of those is the price of prescription medications.

 

I was curious about the prices our patients face for some of the common medications we often send them home with or expect them sometimes for the rest of their lives. Of course, insurance is a whole other issue, but these are just some of the upfront costs that particularly our most vulnerable and socioeconomically destitute patients may face:

 

*prices listed are the lowest price at a pharmacy within 5 miles of the hospital

Albuterol HFA inhaler, $22.14

Amlodipine 5mg, 30 tabs, $5.20

Amoxicillin 400mg/5mL, 100mL bottle, $9.45

Atorvastatin 10, 30 tabs, $6.27

Azithromycin 250, Z pack with 6 tablets, $9.49

Cephalexin 500mg, 30 tabs, $10.86

Ciprofloxacin 500mg, 20 tabs, $17.42

Clopidogrel 75mg, 30 tabs, $6.60

Doxycycline 100mg, 30 tabs, $19.46

Divalproex 500mg, 30 tabs, $14.41

Furosemide 40mg, 30 tabs, $5.10

Gabapentin 300mg, 30 tabs, $6.07

HCTZ 12.5, 30 tabs, $5.58

Ibuprofen 400mg, 30 tabs, $6.65

Levothyroxine 50mcg, 30 tabs, $10.72

Lisinopril 20mg, 30 tabs, $4.99

Metformin 500mg 30 tabs, $4.99

Nitrofurantoin 100mg, 14 tabs, $18.64

Omeprazole 20mg, 30 tabs, $7.47

Prednisone 10mg, 21 tabs, $14.29

Tamsulosin 0.4mg, 30 tabs, $7.77

 

Drug prices are extremely hard to track down. For instance, the NYS DOH website for searching drug prices hasn’t updated their list of prices for our MMC Pharmacy since 2013.

Our wonderful ED pharmacist Ankit Gohel also pointed out to me that you can look up the average wholesale price of any medication on uptodate in the ‘price’ section.

The Epocrates app will also list average retail prices.

Hope this can be some food for thought.

 

Source: www.communitycaresrx.com

https://apps.health.ny.gov/pdpw/SearchDrugs/Home.action

https://www.goodrx.com/

 

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