UMEM Educational Pearls - By Hong Kim

Non-pharmaceutical fentanyl (NPF) is a major contributor to opioid overdoses and overdose fatality. In certain urban areas such as Vancouver, over 80% of heroin samples contain NPF.  For isolated heroin overdose ED patients, they can be safely discharged after brief observation period (~2 hours). However,  “safe” observation time for fentanyl is unknown.

Recently, a retrospective study evaluating the safe observation period in 1009 suspected (uncomplicated) fentanyl overdose ED visits (827 unique patients).

Results:

 In the field:

  • 476 (47.1%) received bystander naloxone
    • 422 (44.1%) had field GCS of 15
    • 547 (57.2%) had pulse oximetry of >= 95%.
  •  EMS administered naloxone to 546 (57.1%) patients (mean dose 0.4 mg IV)

In the ED:

  • 16 patients received additional naloxone in the ED
  • Mean length of stay: 173 minutes (IQR: 101 to 267 minutes)
  • 90% of the patients were discharged within 380 minute.
  • One patient was admitted and one patient died after discharge within 24 hours.

Conclusion:

  • Majority of the patients were safely discharged after 3 - 4 hours after receiving naloxone and if able to maintain GCS 15 with oxygen level 95% while able to ambulate normally.
  • However, some patient may require up to 6 hours of observation.  

Show References



Category: Toxicology

Title: Sometimes more is better: naloxone and clonidine toxicity.

Keywords: clonidine toxicity, high-dose naloxone (PubMed Search)

Posted: 3/18/2018 by Hong Kim, MD, MPH (Emailed: 4/12/2018) (Updated: 4/12/2024)
Click here to contact Hong Kim, MD, MPH

Clonidine, (central alpha-2 receptor agonist) can produce opioid-like toxidrome in addition to its cardiac effects (bradycardia and hypotension). Previous studies have shown that naloxone has variable (~40%) success in reversing CNS/respiratory depression and cardiac effect.

A recent retrospective study (n=51) of pediatric poisoning showed that administration of 5 to 10 mg had improved reversal of clonidine toxicity.

Total of 51 somnolent patients: 5- 10 mg of naloxone reversed 40 patients

  • 22 patients awoke with 6 mg or less
  • Bradycardia reversed in 17 of 44 patients
  • Hypotension reversed in 7 of 11 patients

There was no adverse effect from naloxone administration.

Repeat administration of naloxone was required in some patients.

Bottom line

  • For pediatric clonidine toxicity, consider initial naloxone dose of 5 mg IV. 

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Category: Toxicology

Title: Why is the synthetic cannabinoid use making my patient bleed? - submitted by James Leonard

Keywords: adulterated synthetic cannabinoid, elevated INR, brodifacoum (PubMed Search)

Posted: 4/4/2018 by Hong Kim, MD, MPH
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Question

In the past couple of weeks, there have been reports from Illinois about patients using adulterated synthetic cannabinoids, resulting in elevated INR and bleeding. To date, there are approximately 70 cases including 3 fatalities. Brodifacoum, a long-acting vitamin K mediated anticoagulant (similar to warfarin) has been identified in 10 cases. Brodifacoum is frequently used as rodenticide.

This week, Maryland Poison Center received our first notification of a patient with bleeding and elevated INR due to suspected adulterated synthetic cannabinoid use.

When evaluating our patient population:

  • Ask about synthetic cannabinoid use in patients with unexplained bleeding and elevated INR
  • Carefully examine patients with synthetic cannabinoid intoxication for any signs of bleeding, bruising or petechiae.  
     

Patient management of suspected cases:

  • ACTIVELY bleeding:
    • Fresh frozen plasma
    • Activated prothrombin complex concentrate (KCentra®) in life threatening bleeding.
    • Vitamin K 10 mg IV
    • *** Start oral vitamin K at 50 mg TID and titrate to goal INR < 2 ***
  • NOT bleeding and INR < 10: vitamin K 50 mg PO BID with titration if needed.
  • NOT bleeding and INR > 10: vitamin K 50 mg PO TID with titration if needed.

Patient can be discharged when INR < 2 is achieved with oral vitamine K regimen only (without recent FFP infusion).

Review of published cases highlights that most patients are started on a median doses of 100 mg/day (range: 15 - 600 mg) and stabilize on a PO regimen of 50-100 mg/day. Prolonged PO vitamin K course of 2 – 3 months or longer should be anticipated.

Pease call the Maryland Poison Center at 1-800-222-1222 as we are working with the Maryland Department of Health and CDC to track these cases. 

 

 

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Category: Toxicology

Title: The Russian connection 2.0 -- Sergei Skripal

Keywords: nerve agents, organophosphate compounds (PubMed Search)

Posted: 3/18/2018 by Hong Kim, MD, MPH (Emailed: 3/21/2018) (Updated: 3/21/2018)
Click here to contact Hong Kim, MD, MPH

Recently, an ex-Russian spy and his daughter were poisoned in Salisbury, England using a Soviet nerve agent called Novichok. He joins a list of defectors and ex-spies who's poisoning have been connected to Russia.

Nerve agents are organophosphate compounds, similar to the commercially available pesticides, but significantly more potent. Nerve agents such as VX take seconds to minutes to irreversibly inhibit acetylcholinesterase by “aging” and result in clinical toxicity. 

Signs and symptoms

  • Muscarinic: DUMBELS or SLUDGE and Killer B's
  • Nicotinic: muscle weakness & paralysis

Treatment

  • Decontamination
  • Atropine – 2 mg IV and double the dose every 3 – 5 minutes until clearing of bronchorrhea, bronchospasm and bradycardia
  • Pralidoxime – reverses inhibition of acetylcholinesterases that are not aged


Signs and symptoms of acute cyanide poisoning are not well characterized due to its rare occurrence.  Commonly mentioned characteristics of bitter almond odor and cherry red skin have poor clinical utility.

Recently published review of 65 articles (102 patients) showed that most patients experienced following signs and symptoms:

  1. Unresponsive: 78%
  2. Respiratory failure: 73%
  3. Hypotension: 54%
  4. Cardiac arrest: 20%
  5. Seizure: 20%
  6. Cyanosis: 15%
  7. Odor: 15%
  8. Cherry red skin: 11%

There is no clear toxidrome for cyanide poisoning.

In a poisoned patient, health care providers should consider cyanide in their differential diagnosis in the presence of severe metabolic and lactic acidosis (lactic acid > 8 in isolated cyanide poisoning or > 10 in smoke/fire victim).

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Category: Toxicology

Title: Toxin-induced nystagmus

Keywords: nystagmus, toxic (PubMed Search)

Posted: 2/22/2018 by Hong Kim, MD, MPH
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Abnormal ocular movement (e.g. nystagmus) can often be observed in select CNS pathology.

Certain drugs/toxin overdose can also induce nystagmus.

  • Anti-epileptics: carbamazepine, lamotrigine, topiramate, phenytoin
  • Ethanol
  • Ketamine, phencyclidine (PCP), dextromethorphan – vertical or rotary nystagmus
  • Serotonergic syndrome/5-HT agonists – opsoclonus
  • Monoamine oxidase inhibitors – ping-pong nystagmus
  • Lithium
  • Scorpion envenomation 

In an "unknown" intoxication, physical exam findings such as nystagmus may help narrow the identity of the suspected ingestion/overdose.



Category: Toxicology

Title: Benefit of activated charcoal in large acetaminophen ( >= 40 gm) overdose.

Keywords: activated charcoal, large acetaminophen overdose, NAC dose (PubMed Search)

Posted: 1/11/2018 by Hong Kim, MD, MPH (Updated: 4/12/2024)
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Acetaminophen (APAP) overdose is the leading cause of liver failure in the U.S. and Europe. Large APAP ingestion can result in hepatotoxicity despite the early initiation of n-acetylcysteine (NAC). 

A recently published study from Austrialia investigated the effect of activate charcoal and increasing the NAC dose for large APAP overdose patients (3rd bag: 100 to 200 mg/kg over 16 hours) during first 21 hours of NAC therapy

acetaminophen ratio (first APAP level taken between 4 to 16 hour post ingestion / APAP level on the Rumack nomogram line at that time point) was determined to compare APAP levels at different time points among study sample

e.g.  

first APAP level at 4 hour post ingestion = 400

APAP level on the Rumack APAP nomogram at 4 hour post ingestion = 150

APAP ratio = 400/150 = 2.67

 

Findings:

  1. Activated charcoal (AC): if given within 4 hours, AC significantly decreased the APAP ratio (OR: 1.4 vs. 2.2)
  2. Increased dose of NAC during the first 21 hour significantly decreased the risk of hepatotoxicity (OR: 0.27; 95% CI: 0.08 - 0.94).

 

Conclusion: 

  1. Administration of AC in patients with history of large APAP overdose (>=40 gm) within 4 hour of ingestion can still be beneficial.
  2. Increasing NAC dosing (3rd bag in first 21 hour thearpy) may decrease the risk of hepatotoxicity. 

Note: Any increase in NAC dosing from the standard 21 hour therapy should be performed after consulting your regional poison center.

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Question

 

Different chemical, food or pharmaceutical agent exposure can change the color of the urine.

What could cause this patient's urine to turn green?

Show Answer


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Category: Toxicology

Title: Do you have digoxin-like toxins growing in your backyard?

Keywords: cardioactive steroids, cardioactive glycoside (PubMed Search)

Posted: 11/9/2017 by Hong Kim, MD, MPH (Updated: 4/12/2024)
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Many medications are discovered from plants (quinine – cinchona trees) or organisms (penicillin – mold [penicillicum]).

Digoxin was isolated from foxglove (Digitalis lanata), a colorful floral plant often found in many gardens.  There are other sources of cardioactive steroids (aka cardiac glycosides) that have similar effect as digoxin.

  • Oleander (Nerium oleander)
  • Yellow orleaner (Thevetia peruviana) – frequently used for suicide in Southeast Asia
  • Lily of the valley (Convallari majalis) – use in wedding bouquet
  • Dogbane (Apocynum cannabinum)
  • Red squill (Urginea maritima)
  • Bufo toad (Bufo species)  

 

Non-digoxin cardioactive steroid exposure can result in a positive digoxin level due to cross reactivity. This confirms exposure; however, the “digoxin level” does not represent the true extent of the ingested dose or toxicity. 

Non-digoxin cardioactive steroid toxicity

  • Digibind also binds to non-digoxin cardioactive steroids.
  • However, larger doses are often required (initial dose: 10 to 20 vials) than doses required for digoxin toxicity.   


Category: Toxicology

Title: Agatha Christie 2.0 Strychnine

Keywords: strychnine (PubMed Search)

Posted: 10/26/2017 by Hong Kim, MD, MPH (Emailed: 10/27/2017) (Updated: 10/27/2017)
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Her first book “The mysterious affair at Styles,” Agatha Christie introduced her lead detective in her novels, Hercule Poirot - the Belgian detective.  She also described the death of Mrs. Emily Inglethorp by strychnine.

Strychnine is found in a disc-like seed of strychnos nux-vomica, a tree native to tropical Asia and North Australia.

It is currently used as rodenticide (moles and gophers), in Chinese herbal medicine and a traditional remedy in Cambodia.

Strychnine inhibits binding of glycine (a major inhibitory neurotransmitter in spinal cord) to Cl-channel resulting in identical clinical syndrome – seizure-like generalized muscle contraction with normal mental status – as tetanus toxin. Tetanus toxin inhibits the release of presynaptic glycine in the spinal cord. 

 

Management

Goal: decrease muscle hyperactivity

  • 1st line: benzodiazepine
  • 2nd line: barbiturates or propofol
  • 3rd line: paralysis by non-depolarizing agents


Category: Toxicology

Title: Arsenic and Agatha Christie

Keywords: Arsenic poisoning (PubMed Search)

Posted: 10/19/2017 by Hong Kim, MD, MPH
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Agatha Christie is an English crime novelist who frequently used poisons in her books to murder the victims. In her book, Murder is Easy, Ms. Christie uses arsenic/arsenic trioxide to kill several characters.

 

Primary source of arsenic in general population is contaminated food, water and soil. Arsenic exists in several forms: elemental, gaseous (arsine), organic and inorganic (trivalent or pentavalent).

 

Arsenic trioxide has also been used to treat acute promyelocytic leukemia in China; it’s use in other leukemia, lymphoma, and other solid tumors are currently being investigated.

 

Arsenic primarily inhibits the pyruvate dehydrogenase complex and multiple other enzymes involved in the citric cycle/oxidative phosphorylation, resulting in mitochondrial dysfunction.

 

Acute toxicity of arsenic after ingestion

  1. GI symptoms (minutes to several hours) – nausea, vomiting, abdominal pain and cholera like diarrhea.
  2. Cardiovascular: QT prolongation/torsade de pointes, orthostatic hypotension, ventricular dysrhythmias, myocardial dysfunction and shock.
  3. CNS (days): encephalopathy, delirium, coma, and seizure due to cerebral edema and microhemorrhages.
  4. Respiratory: ARDS, respiratory failure,
  5. Others: AKI, leukemoid reaction, hemolytic anemia, and hepatitis.

 

 Management

  1. Chelation: dimercaptrol (BAL) or succimer
  2. Whole bowel irrigation if radiopaque material is present (abdominal XR)
  3. Electrolyte and fluid management
  4. Cardiac monitoring and pressor support in hypotension


During the past several years, several new classes of diabetic medications were introduced for clinical use, including SGLT2 inhibitors (canagliflozin, dapagliflozin and empagliflozin).

SGLT2 inhibitors prevent reabsorption of glucose in the proximal convoluted tubules in the kidney and does not alter insulin release.

A recent retrospective study (n=88) of 13 poison center data from January 2013 to December 2016 showed

  1. 91% of the patients were asymptomatic.  
  2. 7% developed minor symptoms (tachycardia, nausea/vomiting, abdominal pain, & confusion)
  3. 2% developed moderate symptoms (metabolic acidosis, hypertension [166/101], & hypokalemia)
  4. Hypoglycemia was not reported.

49 patients were evaluated in a health care facility (HCF) with 18 admissions. Referral to HCF was more common in pediatric patients. This was likely due to unfamiliarity with a new mediation and lack of toxicity data.

Other case reports have shown higher incidence of DKA with the therapeutic use of SGLT2 vs. other classes of DM medications.

 

Bottom line:

Limit data is available regarding the toxicologic profile of SGLT2 inhibitors.

Based upon this small retrospective study, hypoglycemia may not occur and majority of the patient experience minimal symptoms.

Show References



There have been reports of “intoxication” or adverse effects among first responders and law enforcement due to exposure to a “powder” suspected to be fentanyl or its analog.

 

This has led to a significant concern among first responders and law enforcement when investigating or handling “powder” at the scene of overdose or drug enforcement related raids. (http://www.foxnews.com/health/2017/08/15/police-department-gets-hazmat-like-protective-gear-for-overdose-calls.html)

 

American College of Medical Toxicology and American Association of Clinical Toxicology recently published a position statement to help clarify the potential health risk associated with exposure to fentanyl and its analogs.

 

  1. Opioid toxicity is unlikely from incidental dermal exposure.
  2. Nitrile gloves provide sufficient protection against dermal exposure.
  3. N95 respirator provide sufficient protection against aerosolize fentanyl/opioids.
  4. Naloxone should be administered for patients with objective signs of opioid toxicity - hypoventilation and CNS depression – not for vague or subjective symptoms.


Category: Toxicology

Title: Idarucizumab for Dabigatran reversal 2.0

Keywords: dabigatran reversal, Idarucizumab (PubMed Search)

Posted: 8/25/2017 by Hong Kim, MD, MPH
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Question

Full cohort analysis idarucizumab for dabigatran associated bleeding was recently published in NEJM.

This study evaluated the laboratory correction of elevated ecarin clotting time or diluted thrombin time induced by dabigatran and time to either cessation of bleeding (Group A: patients with GI bleeding, traumatic bleeding, or ICH) or time to surgery (Group B: patients requiring surgical intervention within 8 hours).

Findings

Group A (n=301): Median time to the cessation of bleeding was 2.5 hours in 134 patients.

HOWEVER:

  • Bleeding cessation could not be determined in 67 patients
  • Cessation of bleeding could not be assess in 98 patients with ICH
  • Bleeding stopped spontaneously in 2 patients.

Group B (n=202): Median time to intended surgery after infusion of idarucizumab was 1.6 hours.

  • Normal hemostasis in 184 patients (93.4%), mildly abnormal in 10, and moderately abnormal in 3.
  • Many received PRBC and other blood products during surgery

Laboratory markers:

100% reversal of abnormal ecarin clotting time or diluted thrombin time within 4 hours after the administration

Mortality

  • 5 Day: Group A: 6.3% vs. Group B: 12.6%
  • 30 Day: Group A: 13.5% vs. Group B: 12.6%
  • 90 Day: Group A: 18.8% vs. Group B: 18.9%

 

Conclusion

Authors concluded thate idaurcizumab is an "effective" reversal agent for dabigatran.

Overall, the findings are more promising compared to the interim analysis that was published in 2015.

 

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Category: Toxicology

Title: Importance of hemodialysis in intubated salicylate poisoned patients

Keywords: salicylate poisoning, endotracheal intubation, hemodialysis (PubMed Search)

Posted: 7/27/2017 by Hong Kim, MD, MPH
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Patients with severe salicylate poisoning may require endotracheal intubation due to fatigue from hyperventilation or mental status change.

A previously published study (Stolbach et al. 2008) showed that mechanical ventilation increases the risk of acidemia and clinical deterioration.

A small retrospective study investigated the impact of hemodialysis (HD) in intubated patients with salicylate poisoning.

 

Findings:

53 cases with overall survival rate of 73.2%

In patients with salicylate level > 50 mg/dL

  • No HD: 56% survival (14/25)
  • HD: 83.9% survival (0/9)

If salicylate level > 80 mg/dL

  • No HD: 0% survival (26/31)
  • HD: 83.3% survival (15/18)

Bottom Line:

There is moratality benefit of HD in intubated salicylate-poisoned patient.

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Hydrogen peroxide (H2O2) is a common household liquid that is used for wound irrigation/antiseptic and cosmetic purposes. The concentration of household product is 3% to 5% and is considered to be relatively safe except in large volume ingestion.

High-concentration H2O2 (>10%) is commercially available as “food grade” (35%) that is diluted for household use or for alternative medicine therapy (i.e. hyperoxygenation).

Ingestion of high-concentration of H2O2 can result in caustic injury as well as ischemic injury from gas embolism.

Ingestion of 1 mL of 3% H2O2 produces 10 mL of O2 gas while 1 mL of 35% H2O2 produces 115 mL of O2 gas.

Common symptoms/findings of H2O2 ingestions includes:

  • Nausea/vomiting
  • Abdominal pain due to gas in portal venous system
  • Caustic injury of GI track (ingestion of > 10% H2O2)
  • Arterialization of O2 gas result in end-organ injury (e.g. CVA)

A retrospective review of  >10% H2O2 ingestion from National Poison Data System showed:

  • 13.9% developed gas embolic event
  • 6.8% experienced permanent disability, including 5 deaths.

Management

  • Minor symptoms: primary supportive
  • CT ABD/Pelvis should be considerd if abdominal pain is present
  • If significant gas is present in portal vein or evidence of end-organ injury (i.e. CVA), HBO therapy is recommended (limited evidence).
  • Endoscopy should be considered in concentrated H2O2 ingestion to evaluate for caustic injury.

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Category: Toxicology

Title: Are you up to date on your street names for drugs of abuse?

Keywords: drugs of abuse, street name (PubMed Search)

Posted: 6/5/2017 by Hong Kim, MD, MPH (Emailed: 6/15/2017) (Updated: 6/15/2017)
Click here to contact Hong Kim, MD, MPH

Street names for illicit substance are diverse and unique. Knowing what your patient used prior to ED presentation can help with the management of their intoxication. 

 

DEA recently released 7 page list of common street names for drugs of abuse. 

 

https://ndews.umd.edu/sites/ndews.umd.edu/files/dea-drug-slang-code-words-may2017.pdf

 

But keep in mind that what our patients purchase and use may not actually contain the drug that they intended to purchase (e.g. fentanyl being sold as heroin).  

 


Attachments

1706051356_dea-drug-slang-code-words-may2017.pdf (2,993 Kb)



Question

Botulism is a rare neurologic condition characterized by GI symptoms that progressed to cranial nerve dysfunction and symmetric descending paralysis. Foodborne botulism is due to ingestion of botulinum toxin that is produced by clostridium botulinum, an ubiquitous bacterium in our environment. 

Bottom line:

  • Foodborne botulism presents with GI symptoms that is followed by symmetric descending flaccid paralysis.
  • Botulinum antitoxin prevents further progression of neurologic deficit; it does not reverse the neurologic deficit that is present prior to administration. 
  • Contact your local poison center, and state health department & CDC regarding management and access to botulinum antitoxin.

Maryland Department of Health and Mental Hygiene

  • During business hours: 410-767-6700
  • After hours: 410-795-7365

CDC Emergency Operations Center: 770-488-7100

Show Answer

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Category: Toxicology

Title: Drug induced lactic acidosis.

Keywords: lactic acidosis (PubMed Search)

Posted: 4/20/2017 by Hong Kim, MD, MPH (Updated: 4/12/2024)
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Lactic acids are often elevated in critical care patients (e.g. septic shock). It can be also elevated in setting of drug overdose or less frequently in therapeutic use due to interference of oxidative phosphorylation. Some of the agents include:

 

  • Carbon monoxide
  • Cyanide
  • Propofol
  • Metformin
  • Propylene glycol
  • Salicylates
  • Beta-2 agonists
  • Thiamine deficiency/alcoholic ketoacidosis
  • Ethylene glycol/toxic alcohols
  • Nucleoside reverse-transcriptase inhibitors

 

Bottom line:

  • Although elevated lactic acid levels are often associated with underlying medical conditions, it is important to recognize drug-induced etiologies of lactic acidosis. 

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Category: Toxicology

Title: Sodium bicarbonate shortage Is there an alternate solution?

Keywords: sodium bicarbonate, sodium acetate (PubMed Search)

Posted: 4/6/2017 by Hong Kim, MD, MPH (Updated: 4/12/2024)
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FDA announced a shortage of sodium bicarbonate on 3/01/17.  Sodium bicarbonate is frequently used in acid-base disorder as well as in poisoning (cardiac toxicity from Na-channel blockade, e.g. TCA & bupropion, and salicylate poisoning).

 

Acetate is a conjugate base of acetic acid where acetate anion forms acetyl CoA and enters Kreb cycle after IV administration. Final metabolic products of acetate are CO2 and H2O, which are in equilibrium with bicarbonate via carbonic anhydrase activity.

 

Administration of sodium acetate increases the strong ion difference by net increase in cations, as acetate is metabolize, and leads to alkalemia.

 

Adverse events from sodium acetate infusion have been associated with its use as dialysate buffer: myocardial depression, hypotension, hypopnea leading to hypoxemia and hyperpyrexia. However, such adverse events have not been reported in toxicologic application.

 

 

Bottom line:

Sodium acetate can be administered safely in place of sodium bicarbonate if sodium bicarbonate is not available due to shortage.

Sodium acetate dose:

  • Bolus: 1 mEq/kg over 15 – 20 min
  • Infusion: 150 mEq in 1L D5%W @ twice maintenance rate   

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