Alkali Therapies

OVERVIEW

  • sodium bicarbonate
  • THAM
  • Carbicarb
  • Dichloroacetate
  • Dialysis / hemofiltration

SODIUM BICARBONATE

  • 8.4% and 4.2% solution
  • hyperosmolar
  • generates high CO2
  • used to treat a metabolic acidosis if pH < 7.1 (controversial)
  • improves vasopressor responsiveness
  • may have role in decreasing contrast nephropathy
  • adverse effects: paradoxical acidosis in the presence of low output, hypokalaemia, phlebitis

THAM

  • Tris-hydroxymethyl aminomethane (THAM)
  • commercially available weak alkali that buffers H+ ions
  • buffering not associated with a CO2 rise
  • adverse effects: hyperkalaemia, hypoglycaemia, extravasation necrosis, hepatic dysfunction

CARBICARB

  • equimolar combination of sodium carbonate and sodium bicarbonate
  • generates a smaller rise in CO2 than sodium bicarbonate
  • more consistently increases intracellular pH
  • inconsistent effects on haemodynamics
  • not commonly used clinically

DICHLOROACETATE

  • works by stimulating the pyruvate dehydrogenase complex which regulates the entry of pyruvate into tricarboxylic acid cycle
  • increases pH
  • decreases lactate
  • RCTs have found no benefit in haemodynamics or patient outcome

DIALYSIS/HAEMOFILTRATION

  • peritoneal dialysis effective at removing lactate
  • bicarbonate-buffered haemofiltration is ineffective
  • avoid lactate based buffers in those who with lactate acidosis or liver disease

CCC Pharmacology Series

Journal articles

  • Gehlbach BK, Schmidt GA. Bench-to-bedside review: treating acid-base abnormalities in the intensive care unit – the role of buffers. Crit Care. 2004 Aug;8(4):259-65. PMC522834.
  • Hoste EA, Colpaert K, Vanholder RC, Lameire NH, De Waele JJ, Blot SI, Colardyn FA. Sodium bicarbonate versus THAM in ICU patients with mild metabolic acidosis. J Nephrol. 2005 May-Jun;18(3):303-7. PMID: 16013019.
  • Kraut JA, Kurtz I. Use of base in the treatment of severe acidemic states. Am J Kidney Dis. 2001 Oct;38(4):703-27. PubMed PMID: 11576874.
  • Morgan TJ. The meaning of acid-base abnormalities in the intensive care unit: part III — effects of fluid administration. Crit Care. 2005 Apr;9(2):204-11. PMC1175908.
  • Naka T, Bellomo R. Bench-to-bedside review: treating acid-base abnormalities in the intensive care unit–the role of renal replacement therapy. Crit Care. 2004 Apr;8(2):108-14. PMC420038.

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the  Clinician Educator Incubator programme, and a CICM First Part Examiner.

He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.

His one great achievement is being the father of three amazing children.

On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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