Bicarbonate Drip in Diabetic Ketoacidosis (DKA)

Bicarbonate therapy in DKA is only indicated when the arterial pH is less than 6.9, and should not be administered when pH is 7.0 or higher. 1

Indications for Bicarbonate Therapy

Bicarbonate therapy may be beneficial in adult patients with severe acidemia with pH < 6.9 1
No bicarbonate therapy is required if pH is ≥ 7.0, as insulin therapy alone is sufficient to resolve ketoacidosis 1
For patients with pH between 6.9-7.0, prospective randomized studies have failed to show either beneficial or deleterious changes in morbidity or mortality with bicarbonate therapy 1
In pediatric patients, if pH remains < 7.0 after the initial hour of hydration, it is recommended to administer 1-2 mEq/kg sodium bicarbonate over the course of 1 hour 1

For adult patients with pH 6.9-7.0, administer 50 mmol sodium bicarbonate diluted in 200 ml sterile water and infused at a rate of 200 ml/h 1
For pediatric patients with pH < 7.0 after initial hydration, administer 1-2 mEq/kg sodium bicarbonate over 1 hour 1
When administering bicarbonate, it can be added to NaCl with any required potassium, ensuring the solution does not exceed 155 mEq/L sodium 1

Monitor serum potassium levels closely as both insulin and bicarbonate therapy lower serum potassium 1, 2
Check blood glucose every 2-4 hours and measure serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH every 2-4 hours 2
Potassium supplementation should be maintained in intravenous fluids and carefully monitored 1

Bicarbonate administration may worsen hypokalemia, requiring more aggressive potassium replacement 3
In patients with DKA and relatively low plasma potassium levels, consider delaying insulin administration and first administer potassium chloride intravenously to bring plasma potassium close to 4 mmol/L 4
Bicarbonate therapy should not be administered to children with DKA except in cases of very severe acidemia with hemodynamic instability refractory to saline administration 4
Excessive bicarbonate administration may contribute to cerebral edema risk, particularly in pediatric patients 4, 5

The evidence regarding bicarbonate use in DKA with pH < 6.9 is limited, as no prospective randomized studies have been reported for this severe pH range 1
Studies have shown no benefit of bicarbonate therapy in patients with pH between 6.9-7.1 3
The American Diabetes Association guidelines assign a grade C (lower rank) to recommendations regarding bicarbonate therapy, indicating evidence from uncontrolled or poorly controlled studies 1
While the FDA label for sodium bicarbonate includes severe diabetic acidosis as an indication 6, clinical guidelines are more restrictive in their recommendations

For pH ≥ 7.0: No bicarbonate therapy is indicated 1
For pH 6.9-7.0: Consider bicarbonate therapy in adults (50 mmol in 200 ml sterile water at 200 ml/h) 1
For pH < 6.9: Bicarbonate therapy is generally indicated, especially if hemodynamic instability is present 4, 7
For pediatric patients: If pH remains < 7.0 after initial hydration, administer 1-2 mEq/kg sodium bicarbonate over 1 hour 1