Should bicarbonate (bicarb) be administered in a patient with Diabetic Ketoacidosis (DKA) and a bicarbonate level of 3?

From the Guidelines

Bicarbonate administration is not recommended for patients with Diabetic Ketoacidosis (DKA) and a bicarbonate level of 3, as the primary treatment should focus on insulin therapy, fluid resuscitation, and electrolyte replacement. The most recent and highest quality study, 1, published in 2024, supports this recommendation, stating that several studies have shown that the use of bicarbonate in people with DKA made no difference in the resolution of acidosis or time to discharge.

Key Considerations

• Insulin therapy itself will stop ketoacid production, allowing the body to correct the acidosis naturally 1.
• Bicarbonate therapy may be considered only in severe cases with pH < 6.9, life-threatening hyperkalemia, or cardiac instability.
• If bicarbonate is deemed necessary in these extreme circumstances, it should be administered as 100 mmol sodium bicarbonate in 400 mL sterile water with 20 mEq KCl infused over 2 hours, followed by reassessment.

Treatment Approach

• The primary treatment for DKA should focus on insulin therapy, fluid resuscitation, and electrolyte replacement, particularly potassium 1.
• Individuals with uncomplicated DKA may sometimes be treated with subcutaneous rapid-acting insulin analogs in the emergency department or step-down units, an approach that may be safer and more cost-effective than treatment with intravenous insulin 1.
• It is essential to provide adequate fluid replacement, frequent bedside testing, appropriate treatment of any concurrent infections, and appropriate follow-up to avoid recurrent DKA 1.

From the Research

Bicarbonate Administration in DKA

• The administration of bicarbonate in patients with Diabetic Ketoacidosis (DKA) is a topic of debate, with some studies suggesting its use in specific cases and others arguing against its routine use.
• A study published in 2019 2 recommends that sodium bicarbonate infusion should be reserved for pH < 6.9, and that the correction of hypokalemia should be prioritized during treatment.
• Another study from 2024 3 suggests that bicarbonate therapy is not necessary in the treatment of DKA, even in cases with severe acidosis, and that the standard regimen of IV fluids, IV insulin, and potassium maintenance is sufficient.

Indications for Bicarbonate Administration

• A study from 1991 4 found that bicarbonate therapy improved the rate of increase of arterial pH in patients with severe DKA, but did not affect the recovery rate of other metabolic abnormalities.
• However, a more recent study from 2013 5 found that intravenous bicarbonate therapy did not decrease the time to resolution of acidosis or time to hospital discharge in patients with DKA, and that its use was associated with higher insulin and fluid requirements.
• The American Diabetes Association recommends the use of intravenous bicarbonate in patients with DKA and a pH < 6.9 5.

Alternative Treatments

• A study from 2020 6 found that the use of balanced crystalloids, such as Ringer's lactate or Plasma-Lyte, resulted in more rapid resolution of DKA compared to saline, and may be a preferred treatment option.
• The use of balanced crystalloids may help to avoid the development of hyperchloremic metabolic acidosis, which can occur with the use of saline 6.

Conclusion is not allowed, so the response will be ended here with the last point.

• It is essential to consider the individual patient's needs and circumstances when deciding whether to administer bicarbonate in DKA, and to carefully monitor their response to treatment 2, 3, 4, 5, 6.