From: David Collette
To: W. Williams, patrick, Emma Strickland, Brittney Shippee, patrick, April Williams, Jonathan Spry, Amanda Ouzts, Adam Sawyer, Sara Jones, Nellie McKee, Jeremy Ray, sharon baty, richard cramer, gregg knowles, jerry robinson, mary dang, michele durda, jonathan edwards, mickala thompson
Cc: Becky Ginn
Sent: Tuesday, October 10, 2017 6:12:22 PM
Subject: sodium bicarb IV

We are beginning to see more IV bicarb trickling in (vials, NOT SYRINGES) and I wanted to let you know where things stand. Michael talked to HH Admin and they do NOT want to release IV bicarb back to unrestricted status at this time...especially since we do not know 100% that the shortage is over and we still cannot get an adequate supply of syringes. Michael has talked to Tracey, David, Jeff, and Dr. Chappel; the current supply of IV bicarb will be presented and discussed at P&T October 24th, then I will meet with MEC on November 14th for a status update and discussion of path forward. We will not be putting IV bicarb in crash carts at the time, but they will continue to be available in the pharmacist kits. IV bicarb will also continue to be available for drips in critical care patients who have documented, clinically-significant metabolic acidosis, as well as other criteria that was approved by P&T at the beginning of the shortage.

In case you are questioned by physicians who are wanting the bicarb restrictions reduced for whatever reason (some have heard that the shortage may be improving and that other hospitals are no longer restricting it), here are brief synopses of references I quickly pulled from the web. All are saying basically the same thing we have been saying...with the most positive comment being "that it is not detrimental and 'should be considered.'" Note that the second author's comments mirror some of our criteria, including the amitriptyline overdose; I also included one on the neonatal population for completeness. I would not lead with these comments nor forward this e-mail, but I wanted you to have the info in case it came up in conversation.

Statement from Society of Critical Care Medicine in 2016 (in response to the national bicarb shortage) "Studies do not support the hypothesis that sodium bicarbonate enhances catecholamine effectiveness."

From the Journal of Clinical Medicine Research in 2016 :
"A t the present time, SB administration is only recommended for cardiac arrest related to hypokalemia or overdose of tricyclic antidepressants. Several studies challenge the assumption that bicarbonate administration is beneficial for treatment of acidosis in cardiac arrest. At the present time, there is a trend against using bicarbonates in cardiac arrest, and this trend is supported by guidelines published by professional societies and organizations."

From a website entitled Evidence Based Medicine in 2016 :
"The bottom line is the literature does not support routine SB use in cardiac arrest . However, there are conflicting, limited data to suggest that it improve rates of ROSC. Additionally, SB does not appear to be detrimental in cardiac arrest. SB use should be considered in the setting of cardiac arrest."

From medical professor at Albert Einstein School of Medicine in 2008 (published on web at Researchgate - the author's exact title was Sodium Bicarbonate: Basically Useless Therapy)
"Common clinical practices often are unsupported by experimental evidence. One example is the administration of sodium bicarbonate to neonates. Despite a long history of widespread use, objective evidence that administration of sodium bicarbonate improves outcomes for patients in cardiopulmonary arrest or with metabolic acidosis is lacking. Indeed, there is evidence that this therapy is detrimental."

This is not an exhaustive literature search, but just four articles that seem to show the current thoughts on use of IV bicarb in critically ill patients. Please feel free to contact me if you have any questions about our IV sodium bicarbonate supply.

DAVID
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David R. Collette, Pharm.D., FASHP
Operations Manager, Professional Services