Original Contribution
The effects of sodium bicarbonate during prolonged cardiopulmonary resuscitation

https://doi.org/10.1016/j.ajem.2012.11.001Get rights and content

Abstract

Background

This study was performed to determine the effects of sodium bicarbonate injection during prolonged cardiopulmonary resuscitation (for > 15 minutes).

Methods

The retrospective cohort study consisted of adult patients who presented to the emergency department (ED) with the diagnosis of cardiac arrest in 2009. Data were retrieved from the institutional database.

Results

A total of 92 patients were enrolled in the study. Patients were divided into 2 groups based on whether they were treated (group1, n = 30) or not treated (group 2, n = 62) with sodium bicarbonate. There were no significant differences in demographic characteristics between groups. The median time interval between the administration of CPR and sodium bicarbonate injection was 36.0 minutes (IQR: 30.5-41.8 minutes). The median amount of bicarbonate injection was 100.2 mEq (IQR: 66.8-104.4). Patients who received a sodium bicarbonate injection during prolonged CPR had a higher percentage of return of spontaneous circulation, but not statistical significant (ROSC, 40.0% vs. 32.3%; P = .465). Sustained ROSC was achieved by 2 (6.7%) patients in the sodium bicarbonate treatment group, with no survival to discharge. No significant differences in vital signs after ROSC were detected between the 2 groups (heart rate, P = .124; systolic blood pressure, P = .094). Sodium bicarbonate injection during prolonged CPR was not associated with ROSC after adjust for variables by regression analysis (Table 3; P = .615; odds ratio, 1.270; 95% confidence interval: 0.501-3.219)

Conclusions

The administration of sodium bicarbonate during prolonged CPR did not significantly improve the rate of ROSC in out-of-hospital cardiac arrest.

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.

References (19)

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Conflict of interest statement: The authors have no conflicts of interest to declare.

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