Bicarbonate Administration in Diabetic Ketoacidosis (DKA)
Bicarbonate therapy is NOT recommended in DKA unless the patient has severe acidemia with pH < 6.9. 1, 2
Indications for Bicarbonate Therapy Based on pH
- pH ≥ 7.0: No bicarbonate therapy is necessary as insulin therapy alone is sufficient to resolve ketoacidosis 3, 1, 2
- pH 6.9-7.0: Evidence is equivocal - prospective randomized studies have failed to show either beneficial or deleterious effects on morbidity or mortality with bicarbonate therapy 3
- pH < 6.9: Bicarbonate therapy may be beneficial in adult patients with this severe level of acidemia 3, 1, 2
Administration Protocol When Indicated
- For pH < 6.9: Administer 100 mmol sodium bicarbonate added to 400 ml sterile water and give at a rate of 200 ml/h 3, 2
- For pH 6.9-7.0: If bicarbonate is deemed necessary, administer 50 mmol sodium bicarbonate diluted in 200 ml sterile water and infused at a rate of 200 ml/h 3
Risks and Monitoring During Bicarbonate Therapy
- Bicarbonate therapy lowers serum potassium, so potassium levels must be closely monitored 3
- Potassium supplementation should be maintained in intravenous fluids during bicarbonate administration 3, 1
- Monitor serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH every 2-4 hours 1
Special Considerations
- In pediatric patients, if pH remains < 7.0 after the initial hour of hydration, consider administering 1-2 mEq/kg sodium bicarbonate over the course of 1 hour 1
- Sodium bicarbonate should generally not be administered to children with DKA, except in cases of very severe acidemia with hemodynamic instability refractory to saline administration 4
Pitfalls to Avoid
- Administering bicarbonate to patients with pH ≥ 7.0 provides no benefit and may potentially cause harm 1, 2
- Failing to monitor potassium levels during bicarbonate therapy can lead to dangerous hypokalemia 2
- Excessive bicarbonate administration may contribute to cerebral edema, particularly in children and adolescents 4, 5