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]. 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. The major mechanism of action of aspirin is mediated via inhibition of cyclooxygenase enzyme, resulting in decreased production of thromboxane A2 and various prostaglandins [53]. The manifestations begin as early as 30 minutes and progress to decompensated metabolic acidosis in about 12 hours, if left untreated. Methanol is not found in Australian methylated spirits. As is the case with any treatment involving IV sodium bicarbonate, administration necessitates frequent monitoring of metabolic parameters (serum electrolytes and renal function), cardiopulmonary, and renal status of the patient. [Kidney transplants from donors burdened metabolic acidosis in the course of poisoning with methanol and carbon monoxide]. An overview of chemical characteristics of commonly used crystalloids is presented in Table 1. In the USA, at least 34% of the population regularly takes at least one prescription medication [1]. However sodium bicarbonate as adjunctive treatment is still controversy. In the vast majority of cases the use of such prescribed medications provides clinical benefit to patients. Patients with oliguric/anuric renal failure and advanced decompensated heart failure should not receive IV sodium bicarbonate. B. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. Patients with anuric renal failure should not receive IV sodium bicarbonate but rather be evaluated for renal replacement therapy [55]. Based on clinical experience and available literature, the majority of patients tend to respond via improvement in hemodynamic and ECG parameters. The infusion rate should be titrated to target a urine pH 7.5–8. 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]. According to the Center for Disease Control, in 2013, at least 2113 human fatalities attributed to poisonings occurred in the United States of America. The management of the toxicities mentioned above is complicated, requiring additional measures than sodium bicarbonate alone. Review articles are excluded from this waiver policy. Since sodium bicarbonate can cause alkalosis, it is sometimes used to treat aspirin overdoses. Frequency of laboratory testing and electrocardiographic monitoring should be individualized. Carbonic acid in turn dissociates into bicarbonate () and hydrogen ion (H+) with the latter being removed via kidneys. Laboratory testing and diagnosis are based on the presence of high anion gap metabolic acidosis, the presence of a serum osmolal gap (the difference between measured and calculated osmolality > 10), and measuring the levels of toxic alcohols (used for confirmation; typically, this testing is not time sensitive, and the treatment should not be withheld in any patient suspected of having toxic alcohol ingestion). A new approach to the classification of antiarrhythmic drugs based on their actions on arrhythmogenic mechanisms,”, C. E. Stafstrom, “Mechanisms of action of antiepileptic drugs: the search for synergy,”, J. M. Dupuy, M. J. Ostacher, J. Huffman, R. H. Perlis, and A. Blood gas analysis every two hours is indicated for monitoring to prevent severe alkalemia (arterial pH > 7.60) [55, 56]. Knowledge of the patho-physiological changes that occur in the body after methanol consumption is essential for all practicing doctors. The scientific data on the use of sodium bicarbonate in the management of TCA toxicity is predominantly originated from animal studies, case reports, and case series [32, 33]. 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]. A repeat level may sometimes be obtained two hours after hemodialysis to exclude rebound. Along with water, … 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/. It is important to note that mild alkalemia from a respiratory alkalosis (arterial pH < 7.55) is not a contraindication to sodium bicarbonate therapy in salicylate poisoning. 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. The authors declare that they have no conflicts of interest regarding the publication of this paper.  |  Seizures, hypoglycemia and blindness frequently complicate the picture. As was discussed above, IV sodium bicarbonate may have serious undesired effects including hypokalemia. Clipboard, Search History, and several other advanced features are temporarily unavailable. Intravenous sodium bicarbonate therapy should be considered if the blood pH is below 7.2. In patients with salicylate intoxication, the beneficial effects of sodium bicarbonate are mediated by the production of metabolic alkalosis that decreases the amount of lipid soluble salicylate and driving the above reaction to the left resulting in decreased penetration into central nervous system and in increased urinary clearance [56]. IV administration of sodium bicarbonate may result in enhanced urinary excretion of certain chemicals through urinary alkalinization [56]. 2017 May;69(5):696-700. doi: 10.1053/j.ajkd.2016.10.029. Finally, we will discuss the place of sodium bicarbonate in the management of toxic alcohol ingestions. In conclusion, the literature on the use of sodium bicarbonate in the management of sodium channel blocker toxicities is limited to animal research and case series; randomized trials are precluded due to ethical reasons. Aspirin requires an acidic environment for proper absorption, and the basic environment diminishes aspirin absorption in the case of an overdose. When administered, sodium bicarbonate dissociates into a molecule of sodium and bicarbonate. 12-lead ECG of sodium channel blocker toxicity before and after administration of sodium bicarbonate is presented in Figures 2(a) and 2(b). Metformin toxicity is another instance where sodium bicarbonate may be used [60]. The potential mechanisms of sodium bicarbonate administration include high sodium load, development of metabolic alkalosis with resultant decreased tissue penetration of the toxic substance, and its increased urinary excretion, while, on IV sodium bicarbonate, the patients must be monitored for the development of associated side effects including electrolyte abnormalities (hypokalemia, hypocalcemia, and hypernatremia), progression of metabolic alkalosis volume overload, worsening respiratory status (volume overload and increased CO2 production), and worsening metabolic acidosis (paradoxical increase in lactic acid production secondary to the activation of glycolytic enzymes). Methanol toxicity can have devastating visual consequences and retinal specialists should be aware of the features of this toxic optic neuropathy. 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. Serum sodium and osmolality tend to increase which may lead to cellular dehydration and systemic hypervolemia [13]. The goal of this article is to review the data and evidence on the use of sodium bicarbonate in the management of some pharmacological overdoses. NLM Copyright © 2017 Aibek E. Mirrakhimov et al. Sodium bicarbonate possesses the ... (valium) cyclic antidepressants (amytriptayine), organophosphates, methanol (Methyl alcohol is a cheap and potent adulterant of illicit liquors) Diphenhydramine (Benedryl), Beta blockers (propanalol) Barbiturates, and Salicylates (Aspirin). A. Kriegsman and B. G. Hanna, “Metformin-associated lactic acidosis in a patient with normal renal function,”. 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]. A simplified view on the bicarbonate chemistry is provided in Figure 1. While receiving sodium bicarbonate, patients must be monitored for the development of associated side effects including electrolyte abnormalities, the progression of metabolic alkalosis, volume overload, worsening respiratory status, and/or worsening metabolic acidosis. [Usefulness of blood formic acid detection in the methanol poisoning in the practice of clinical toxicology department-preliminary assessment]. Omeprazole and Sodium Bicarbonate capsules can cause serious side effects, including: A type of kidney problem (acute tubulointerstitial nephritis). Under extreme conditions such as shock states and impaired ventilation, carbon dioxide may accumulate, leading to worsening acidosis [8, 9]. Despite being an effective class, it is notorious for its narrow therapeutic index and major side effect profile in cases of overdose. July 2014 . Field, H. Nohara, and K. Yamashita, “Counterproductive effects of sodium bicarbonate in diabetic ketoacidosis,”, W. A. Neill and M. Hattenhauer, “Impairment of myocardial O2 supply due to hyperventilation,”, J. R. Wilson, S. Goldberg, J. W. Hirshfeld, and A. H. Harken, “Effects of respiratory alkalosis on coronary vascular dynamics and myocardial energetics in patients with coronary artery disease,”, C. H. Peters and P. C. Ruben, “Introduction to sodium channels.,”, M. R. Rosen and P. J. Schwartz, “The Sicilian gambit. 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. However, in some cases, these medications may result in harm including a severe illness and death due to intentional or unintentional overdose or as a result of idiosyncratic drug reaction. The basic steps in approach must be carried out in the emergency department and followed-up with meticulous monitoring in the intensive care unit for salvage as well as prevention of long term sequelae. Adverse reactions to commonly prescribed medications and to substances of abuse may result in severe toxicity associated with increased morbidity and mortality. ... correction of acidosis with sodium bicarbonate, intubation and mechanical ventilation and 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]. 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. Bicarbonate is an essential chemical regulating the acid-base balance acting as a buffer [2]. these results, the suspicion of methanol poisoning was reinforced and the patient was admitted to the Intensive Care Unit (ICU) to receive the treatment, requiring mechanical ventilation, serum therapy, antidote with intravenous ethanol, sodium bicarbonate and folic acid, and hemodialysis to purify methanol molecules. We will first briefly review the mechanisms of metabolic acidosis related biochemical derangements since some of the overdoses are associated with metabolic acidosis. 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. Salicylates are a group of pharmacological agents that include aspirin, bismuth salicylate, and local skin preparations such as salicylic acid and methyl salicylate (topical preparations that rarely cause toxicity if used in an excessive amount or in patients with skin damage leading to increased absorption) [51, 52]. However, most of the data originates from case reports, case series, and expert consensus recommendations. Salicylic acid (HS) is a weak acid that exists in a charged (deprotonated, sal−) and uncharged (protonated, H+) form: H+ + sal−  ⇔ HS. Sodium bicarbonate (NaHCO3) is one of the few pharmacological agents aiming to mimic the endogenous effects of . The use of sodium bicarbonate is also common as methanol can lead to acidosis. B. Mowry, D. A. Spyker, L. R. Cantilena Jr., N. McMillan, and M. Ford, “2013 annual report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 31st annual report,”, G. F. O'Malley, “Emergency department management of the salicylate-poisoned patient,”, A. T. Proudfoot, E. P. Krenzelok, and J. 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]. CO2 penetrates cellular membranes easily, and through this ability may exacerbate intracellular acidosis. NIH The decrease in the blood pH will favor formation of lipid soluble salicylic acid which easily penetrates blood-brain barrier and undergoes renal reabsorption [55]. IV administration of sodium bicarbonate represents only one aspect of the complex management of medication and chemical toxicities, and, for a thorough discussion of the management of these toxicities, the reader is referred to focused reviews. To understand the basic pathogenesis of methanol and ethylene glycol toxicity, it is important to review briefly the metabolism in vivo. Ad Hoc committee,”, D. G. Barceloux, G. R. Bond, E. P. Krenzelok, H. Cooper, and J. In rare circumstances (such as acute illness and worsening renal function), metformin administration may result in the development of lactic acidosis that is believed to be secondary to mitochondrial dysfunction, with a shift towards anaerobic glycolysis [60–62]. The concurrence of cases from a particular area raises doubts about methanol as the culprit. Con rmation is by determining the plasma levels of methanol. 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. ASA toxicity impairs glucose metabolism; Alkalinization of plasma and urine. The metabolism of methanol is responsible for the transformation of methanol to its toxic metabolites, especially formic acid. 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. The final products of methanol and ethylene glycol metabolism are formic acid and oxalic acid, respectively [57]. Sodium bicarbonate has also been used in the treatment of tricyclic antidepressant overdose. The Role of Sodium Bicarbonate in the Management of Some Toxic Ingestions, Department of Medicine, University of Kentucky College of Medicine, Lexington, KY, USA, University of Kansas Medical Center, Kansas City, KS, USA, http://www.cdc.gov/nchs/data/hus/hus14.pdf#085, Carbamazepine, Lamotrigine, Zonisamide, Lacosamide, Cocaine, local anesthetics, Thioridazine, Propranolol, Amantadine, Chloroquine, Hydroxychloroquine, Cyclobenzaprine, K. Alka and J. R. Casey, “Bicarbonate transport in health and disease,”, T. Dybvik, T. Strand, and P. A. Steen, “Buffer therapy during out-of-hospital cardiopulmonary resuscitation,”, R. B. Vukmir and L. Katz, “Sodium bicarbonate improves outcome in prolonged prehospital cardiac arrest,”, S. S. Brar, A. Y.-J. Patients with oliguric/anuric renal failure and advanced decompensated heart failure should not receive sodium bicarbonate. Epub 2017 Jan 19. Please enable it to take advantage of the complete set of features! Sodium bicarbonate is the active ingredient in baking soda. List of some drugs with sodium channel blocking properties. Key facts • Methanol is a widely available chemical with a range of uses including as a solvent, in chemical synthesis and as a fuel. B. Gorin, J. Yacoub, and N. E. Madias, “Assessing acid-base status in circulatory failure. We are committed to sharing findings related to COVID-19 as quickly as possible. 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]. 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]. 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. Sign up here as a reviewer to help fast-track new submissions. 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). Antidotes are available for a range of poisons and can reverse or reduce toxicity, such as naloxone for opioid poisoning, alcohol or fomepizole for toxic alcohols, oxygen for carbon monoxide, chelators for certain metals, sodium bicarbonate for sodium channel blocking agents, methylene blue for methemoglobinemia, and others. 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]. Moderate metabolic acidosis: 50 to 150 mEq sodium bicarbonate diluted in 1 L of D5W to be intravenously infused at a rate of 1 to 1.5 L/hour during the first hour. A. Vale, “Position Paper on Urine Alkalinization,”, J. This article elucidates the clinical presentation and emergency management of these cases under the framework of basic physiological and biochemical phenomena after methanol exposure. Lastly, serious skin injuries can occur in the setting of extravasation of hypertonic bicarbonate solutions, and whenever possible it should be administered through large bore intravenous lines or central venous lines. Aggressive treatment included ethanol drip, bicarbonate and hemodialysis. 1. With methanol poisoning, substantial treatment delays may occur because the clinician is falsely reassured by the initial lack of severe symptoms. Sodium Bicarbonate Injection is used for Urine alkalization, Gastric lavage in methanol poisoning, Heart burn, Acidity in the blood, Heartburn and other conditions. Clinically the effects of sodium channel blockade may present as cardiac arrhythmias and hemodynamic instability [29]. These cardiotoxins are responsible for more fatal dysrhythmias annually than any other class of medications. Early after an ingestion of too much baking soda, vomiting and diarrhea are common as the body tries to correct the high sodium concentration by pulling more water into the digestive tract. Methanol and ethylene glycol are alcohols commonly used in household solutions such as various cleaners, solvents, machine fluids, and antifreeze solutions [57]. 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). 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]. Fundoscopic examination and arterial blood gas analysis are the key diagnostic elements. Decreased vision may start as early as twelve hours after exposure. He survived and regained his eyesight in spite of this degree of elevation of the serum methanol level. etoxicmethanoldoseis mL(mg/kg), Other medications such as antiarrhythmics [36–38], non-TCA antidepressants [39, 40], antiepileptic medications [41–43], cyclobenzaprine [43, 44], propranolol [45], cocaine [46], and certain antihistamines [47] may produce similar ECG and clinical manifestations with favorable response to similarly administered IV sodium bicarbonate. Severe metabolic acidosis: 90 to 180 mEq sodium bicarbonate diluted in 1 L of D5W to be intravenously infused at a rate of 1 to 1.5 L/hour during the first hour. TCAs were responsible for approximately 58% of all antidepressant medications related fatal toxicities in 2013 [22]. However, it seems very unlikely that randomized controlled trials assessing the impact of sodium bicarbonate will be performed due to ethical concerns. 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