Evaluation of a Visual Aid on Calcium and Sodium Bicarbonate Use in Cardiac Arrest

Current American Heart Association guidelines do not recommend routine administration of calcium and sodium bicarbonate for Advanced Cardiac Life Support. A 2024 internal review found inappropriate use in 61% of calcium and 47% of sodium bicarbonate administrations during cardiac arrest. In response, visual indication labels were added to emergency drug trays. The primary objective of this study evaluated whether these alerts reduced inappropriate use of calcium and sodium bicarbonate use during cardiac arrest events.

This is an IRB approved, retrospective cohort study of adult patients (age ≥ 18) with a cardiac arrest event between October 1, 2024, and October 1, 2025. Patients were excluded for incomplete documentation of cardiac arrest events and those presenting to the emergency department in out-of-hospital cardiac arrest. The primary outcome was utilization of calcium and/or sodium bicarbonate without an appropriate indication. Appropriate indications for calcium were defined as serum potassium ≥ 6 mEq/L and calcium channel blocker overdose. For sodium bicarbonate, appropriate indications included serum potassium ≥ 6 mEq/L, severe acidosis (pH < 7.2), and sodium channel blocker overdose. The secondary outcome was patient survival to hospital discharge. Primary and secondary outcomes were analyzed using chi-square tests.

A total of 224 events were analyzed for inclusion, of which, 167 events met inclusion criteria. There were 54 events (24%) excluded for incomplete documentation. Calcium and sodium bicarbonate were administered in 23% and 22% of cardiac arrest events, respectively. For the primary outcome, 74% of patients receiving calcium and 54% receiving sodium bicarbonate lacked an appropriate indication. There were no statistically significant differences in appropriate administration compared with pre-implementation data (calcium p = 0.22; sodium bicarbonate p = 0.47). For the secondary outcome, 8% patients receiving calcium and 0% patients receiving sodium bicarbonate survived to hospital discharge.

Implementation of a visual alert in emergency medication trays did not provide a statistically significant difference in administration of calcium and sodium bicarbonate with an appropriate indication. There were numerically decreased rates of appropriate administrations of both medications after implementation of a visual alert.