Saturday August 18, 2007


Case: You have been called to 'code blue' with patient in PEA (pulseless electrical activity). You tried rounds of epinephrine and atropine beside IVF wide open, without any success. While in that chaos you heard 2 suggestions - one for 'soda-bicarb' and other for 'calcium chloride'. You decide to try both !. What would be other advise you will give with order ?

Answer: First of all calcium is not recommended in PEA unless there is a specific indication like evidence or suspicion of hyperkalemia (as in renal failure patients) or hypocalcemia or calcium channel-blocker overdose. It may have potential serious complications 1.

Also, routine administration of sodium bicarbonate is discouraged because it worsens intracellular and intracerebral acidosis and failed to show any improvement in mortality rate. It should be reseved for patients with severe systemic acidosis, hyperkalemia, or a tricyclic antidepressant overdose.

In case, for above reasons, if you decide to use both sodium bicarbonate and calcium - Give order with advise - "Use different lines for both". It's a simple chemistry. NaHCO3 and CaCl in the same line will form together CaCO3. Also, it is advisable to give soda-bicarb before calcium to avoid above reaction and to avail the benefit of soda-bicarb and once utilized, give calcium.


Related previous pearls: Calcium in Dig toxicity and In Hyperkalemia !!




Reference:

1. Critical Care Medicine: The Essentials - Marini and Wheeler, Page 335