LAUSR

bicarbonate, the preferred treatment for several poisonings. Fortunately, sodium acetate appears to be an adequate alternative for serum alkalinization, urinary alkalinization, and sodium ion loading. Neavyn et al reviewed the literature supporting sodium acetate as a substitute antidote during a previous sodium bicarbonate shortage in 2012. Although sodium acetate will correct a metabolic acidosis, prospective studies in the treatment of tricyclic antidepressants poisoning or salicylism are lacking. We recently treated a 16-year-old girl with depression and a previous suicide attempt who was transferred to our hospital with seizures, wide complex dysrhythmia (QRS interval >160 ms with R0 in the aVR lead and tachycardia), hypotension (blood pressure 84/58 mm Hg), and cardiac arrest after apparent tricyclic antidepressant overdose. She received a 100-mEq bolus of sodium bicarbonate, which narrowed her QRS interval to 106 ms. Because of the apparent sodium channel blockade and its reversal with sodium bicarbonate, we elected to continue serum alkalinization by starting an infusion. However, because of a severe shortage of sodium bicarbonate at our facility, we started an infusion of sodium acetate 150 mEq in 1 L of 5% dextrose at 100 mL/hour, which was rapidly increased to 180 mL/hour. Her serum pH increased from 7.40 to 7.47 after 3 hours of the sodium acetate infusion, and her urine pH increased from 5.5 to 8.5 by 15 hours of treatment. These results are consistent with those of a study on urinary alkalinization with sodium acetate in the setting of high-dose methotrexate therapy. Our patient had prolonged hypotension requiring vasopressors, which is a potential adverse effect of sodium acetate. Additionally, she developed hypokalemia, a common adverse effect of serum and urinary alkalinization with either sodium acetate or sodium bicarbonate. She also developed pneumonia and acute respiratory distress syndrome, requiring prolonged intubation and mechanical ventilation as a result. However, this developed after the sodium acetate infusion was discontinued, her hemodynamics had stabilized when vasopressors were discontinued, and her mental status had returned to normal. Although limited data exist for the use of sodium acetate for urine and serum alkalinization as antidotal therapy, this case demonstrates rapid alkalinization of urine and serum with sodium acetate infusion.