Original ContributionThe effects of sodium bicarbonate during prolonged cardiopulmonary resuscitation☆
Introduction
The use of buffer therapy in cardiac arrest is a source of debate. The use of sodium bicarbonate, which is the principal drug for buffer therapy, was originally based on the assumption that correcting metabolic acidosis could improve the outcomes in cardiac arrest. Bar-Joseph et al. reported that the resuscitation outcomes in emergency medical systems improved in correlation with the increased use of sodium bicarbonate during cardiopulmonary resuscitation (CPR) [1]. However, further studies and randomized controlled trials (RCTs) failed to demonstrate the benefit of buffer therapy in out-of-hospital cardiac arrest (OHCA) [2], [3], [4]. Furthermore, hypernatremia, alkalosis, and excess carbon dioxide production have been associated with sodium bicarbonate injection during CPR [4], [5], [6]. Therefore, the 2010 American Heart Association guidelines for advanced cardiac life support did not recommend the routine use of sodium bicarbonate during CPR, except for pre-existing metabolic acidosis, hyperkalemia, and tricyclic antidepressant intoxication [7].
In contrast to the routine use of sodium bicarbonate during CPR, the use of sodium bicarbonate during prolonged CPR could be beneficial. Animal studies have shown the benefits of buffer therapy during prolonged cardiac arrest [8], [9], [10], [11]. In one RCT, Vukmir et al showed a trend towards an improvement in the outcomes of prolonged resuscitative efforts (> 15 minutes) associated with the use of sodium bicarbonate [3]. In addition, the low prevalence of bystander CPR and the high proportion of patients with an initial shockable rhythm may have contributed to prolonged arrest [12], [13], [14], [15]. Although public education and rising awareness of the importance of bystander CPR is crucial [16], [17], the role of buffer therapy during prolonged CPR should also be explored. Nevertheless, the number of human studies investigating the effects of sodium bicarbonate use during prolonged CPR is limited. There are currently no guidelines regarding the use of sodium bicarbonate in OHCA after prolonged CPR on admission to the emergency department (ED).
The present study aimed to determine the effects of sodium bicarbonate during prolonged CPR (> 15 minutes) in OHCA [3]. We hypothesized that the use of sodium bicarbonate during prolonged CPR may improve the rate of return of spontaneous circulation (ROSC) and survival to discharge in patients with OHCA.
Section snippets
Study design and setting
This was a retrospective cohort study conducted at a university-affiliated teaching hospital with approximately 130,000 visits annually. Patients were treated by emergency physicians. An estimated ROSC, sustained ROSC and survival to discharge rate of conventional resuscitation standards were 30%, 15% and 6% in our city pre-hospital arrests, respectively. This study was approved by the Hospital Ethics Committee on Human Research. The study protocol was reviewed and qualified as exempt from the
Results
A total of 214 patients with ICD-9 cardiac arrest diagnosis codes 7981, 7982, and 7989 were recruited during the study period. Of these, 122 patients were excluded from the study: 33 had incomplete records, 11 lacked results of blood gas tests or chemical studies, 25 had DNR orders, 35 had no EMS activated, and 18 developed ROSC within 15 minutes. The high exclusion rate is due to our strictly defined inclusion criteria, which minimized the influence of selection bias. Finally, 92 patients were
The Effects of Sodium bicarbonate use during prolonged CPR
In the present study, the outcome of OHCA with prolonged CPR (> 15 minutes) was poor, with a rate of survival to discharge of 2.2% (2/92). Although the use of sodium bicarbonate during prolonged CPR increased the rate of ROSC (40.0 vs. 32.3 %), but not statistical significant. Only 6.7% of the patients had sustained ROSC (> 20 minutes) and survival to discharge was 0% in buffer therapy group. Despite the small sample size with limited outcomes of sustained ROSC or survival to discharge, our study
Conclusions
Our study failed to demonstrate the benefit of using sodium bicarbonate during prolonged CPR.The administration of sodium bicarbonate did not significant improve the rate of ROSC in such condition.
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The effect of sodium bicarbonate on OHCA patients: A systematic review and meta-analysis of RCT and propensity score studies
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2020, Journal of Emergency MedicineThe association of emergency department administration of sodium bicarbonate after out of hospital cardiac arrest with outcomes
2018, American Journal of Emergency MedicineCitation Excerpt :In the second trial conducted at Western Pennsylvania, Vukmir et al. demonstrated that there was a significant trend toward increased survival to ED arrival in the subgroup of patients with prolonged (>15 min) cardiac arrest. Other clinical or experimental studies have shown that sodium bicarbonate has a role in favorable outcomes during resuscitation [10,13,15,37-40]. In addition, a recent study in Korea reveals that sodium bicarbonate is associated with increased ROSC during on-going resuscitation after matching patients with ROSC to non-ROSC with blood bicarbonate level and resuscitation duration [11].
Drugs in Out-of-Hospital Cardiac Arrest
2018, Cardiology ClinicsPrehospital sodium bicarbonate use could worsen long term survival with favorable neurological recovery among patients with out-of-hospital cardiac arrest
2017, ResuscitationCitation Excerpt :Several small studies have demonstrated potential drawbacks of prehospital SB use. Weng prospectively assessed 92 patients with >15 min of resuscitation and demonstrated abysmal survival in both SB (0%) and non-SB groups (3.2%) [5]. For 269 in-hospital arrest patients, SB was associated with decreased 1-h survival [4].
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Conflict of interest statement: The authors have no conflicts of interest to declare.