sodium citrate and citric acid

(soe-dee-um sye-trate and sit-rik as-id) sodiumcitrateandcitricacid,

Bicitra

(trade name),

Oracit

(trade name),

PMS-Dicitrate

(trade name),

Shohl’s Solution modified

(trade name)

Classification

Therapeutic: antiurolithics
Pharmacologic: alkalinizing agents
Pregnancy Category: C

Indications

Management of chronic metabolic acidosis associated with chronic renal insufficiency or renal tubular acidosis.Alkalinization of urine.Prevention of cystine and urate urinary calculi.Prevention of aspiration pneumonitis during surgical procedures.Used as a neutralizing buffer.

Action

Converted to bicarbonate in the body, resulting in increased blood pH.As bicarbonate is renally excreted, urine is also alkalinized, increasing the solubility of cystine and uric acid.Neutralizes gastric acid.

Therapeutic effects

Provision of bicarbonate in metabolic acidosis.Alkalinization of the urine.Prevention of cystine and urate urinary calculi.Prevention of aspiration pneumonitis.

Pharmacokinetics

Absorption: Well absorbed following oral administration.Distribution: Rapidly and widely distributed.Metabolism and Excretion: Rapidly oxidized to bicarbonate, which is excreted primarily by the kidneys. Small amounts (<5%) excreted unchanged by the lungs.Half-life: Unknown.

Time/action profile (effects on serum pH)

ROUTE	ONSET	PEAK	DURATION
PO	rapid (min–hr)	unknown	4–6 hr

Contraindications/Precautions

Contraindicated in: Severe renal insufficiency;Severe sodium restriction;HF, untreated hypertension, edema, or toxemia of pregnancy.Use Cautiously in: Obstetric / Lactation: Safety not established.

Adverse Reactions/Side Effects

Gastrointestinal

diarrhea

Fluid and Electrolyte

fluid overload
hypernatremia (severe renal impairment)
hypocalcemia
metabolic alkalosis (large doses only)

Musculoskeletal

tetany

Interactions

Drug-Drug interaction

May partially antagonize the effects of antihypertensives.Urinary alkalinization may result in ↓ salicylate or barbiturate levels or ↑ levels of quinidine, flecainide, or amphetamines.

Route/Dosage

Adjust dosage according to urine pH. Contains 1 mEq sodium and 1 mEq bicarbonate/mL solutionAlkalinizerOral (Adults) 10–30 mL solution diluted in water 4 times daily.Oral (Children) 5–15 mL solution diluted in water 4 times daily.AntiurolithicOral (Adults) 10–30 mL solution diluted in water 4 times daily.Neutralizing BufferOral (Adults) 15–30 mL solution diluted in 15–30 mL of water.

Availability

Oral solution: 500 mg sodium citrate/334 mg citric acid/5 mL (Bicitra, PMS-Dicitrate), 490 mg sodium citrate/640 mg citric acid/5 mL (Oracit)

Nursing implications

Nursing assessment

Assess patient for signs of alkalosis (confusion, irritability, paresthesia, tetany, altered breathing pattern) or hypernatremia (edema, weight gain, hypertension, tachycardia, fever, flushed skin, mental irritability) throughout therapy.
Monitor patients with renal dysfunction for fluid overload (discrepancy in intake and output, weight gain, edema, rales/crackles, and hypertension).
Lab Test Considerations: Prior to and every 4 mo throughout chronic therapy, monitor hematocrit, hemoglobin, electrolytes, pH, creatinine, urinalysis, and 24-hr urine for citrate.
- Monitor urine pH if used to alkalinize urine.

Potential Nursing Diagnoses

Deficient knowledge, related to medication regimen (Patient/Family Teaching)

Implementation

Oral: Solution is more palatable if chilled. Administer with 30–90 mL of chilled water. Administer 30 min after meals or as bedtime snack to minimize saline laxative effect.
- When used as preanesthetic, administer 15–30 mL of sodium citrate with 15–30 mL of chilled water.

Patient/Family Teaching

Instruct patient to take as directed. Missed doses should be taken within 2 hr. Do not double doses.
Instruct patients receiving chronic sodium citrate on correct method of monitoring urine pH, maintenance of alkaline urine, and the need to increase fluid intake to 3000 mL/day. When treatment is discontinued, pH begins to fall toward pretreatment levels.
Advise patients receiving long-term therapy on need to avoid salty foods.

Evaluation/Desired Outcomes

Correction of metabolic acidosis.
Maintenance of alkaline urine with resulting decreased stone formation.
Buffering the pH of gastric secretions, thereby preventing aspiration pneumonitis associated with intubation and anesthesia.