In a prior post, we discussed the use of an initial insulin bolus in the management of diabetic ketoacidosis (DKA). Today we will address another facet of DKA management, for which there is less than optimal evidence and that is: Any benefit to sodium bicarbonate in DKA? Consensus guidelines for the management of DKA recommended administering sodium bicarbonate to DKA patients who present with an initial blood gas pH of < 7.0. That recommendation was updated and changed in 2009 to limit sodium bicarbonate use to DKA patients with blood gas pH of < 6.9. More recently, Chua et al. published a systematic review of 44 articles discussing bicarbonate administration and Duhon et al. published the largest retrospective review of DKA patient with presenting pH of < 7.0.
What are the most recent studies evaluating: Any benefit to sodium bicarbonate in DKA?
The most interesting and revealing observation in reviewing this data is that there is significant heterogeneity when discussing bicarbonate therapy in DKA
If you are going to initiate bicarbonate, what clinical endpoint are you treating to, how much bicarbonate are you going to order, how are you going to administer it, and if you are seeking resolution of academia, what is your threshold cut off for resolution? Finally, do any of these endpoints have any clinical significance in patient outcomes? In the end no, bicarbonate administration makes numbers look transiently better, but does not change any clinically relevant outcomes based on the best evidence to date. Unfortunately, even with all of the DKA that presents to emergency departments, we do not have more robust, prospective, randomized and placebo controlled trials to help us address this clinically un-answered question that dates back to the beginnings of Emergency Medicine as a specialty, but at this time best evidence does not support the role of bicarbonate in treatment of DKA.
Take Home Points
- Neither a recent systematic review, nor largest single retrospective cohort of severe DKA support routine use of bicarbonate therapy in DKA
- Bicarbonate is associated with risk of cerebral edema and prolonged hospitalization in pediatric DKA
- Chua HR et al. Bicarbonate in Diabetic Ketoacidosis – A Systematic Review. Ann Intensive Care 2011. PMID: 21906367
- Duhon B et al. Intravenous Sodium Bicarbonate Therapy in Severly acidotic Diabetic KEtoacidosis. Ann Pharmacother 2013. PMID: 23737516
Other posts on…Any Benefit to Sodium Bicarbonate in DKA?:
- Checkout the great post by Anand Swaminathan at www.emdocs.net on some myths about DKA management
- Also checkout this great post by Josh Farkas on PulmCrit called Four DKA Pearls