Overview
This talk addresses whether sodium bicarbonate should be administered in cases of diabetic ketoacidosis (DKA), reviewing physiologic reasoning, available evidence, and specific clinical scenarios where its use may be justified.
Clinical Case Presentation
- Adult female with type 1 diabetes presented with severe DKA after running out of insulin.
- Labs: pH 6.6, bicarbonate 1.5, CO2 19, anion gap 29, potassium 7.2, glucose >1000, GCS 9, hypotensive, tachypneic (RR in 50s).
Debate on Sodium Bicarbonate in DKA
- Online poll showed polarized opinions; academic purists generally oppose routine bicarbonate use.
- Main arguments against: physiologic risk of worsening acidosis and lack of high-level supporting evidence.
- Absence of evidence does not prove lack of benefit; clinical complexity sometimes defies simple physiologic reasoning.
Evidence-Based Approach and General Management
- Core treatment in all DKA cases is insulin administration.
- Preference for balanced crystalloids (e.g., lactated Ringer’s) over normal saline to avoid worsening acidosis.
- Monitor mental status to assess risk of aspiration; consider non-invasive ventilation alternatives.
- Avoid routine sodium bicarbonate usage in most DKA patients.
Specific Scenarios for Bicarbonate Use
- Consider sodium bicarbonate if pH < 6.9 and at least one of:
- Severe hyperkalemia (with or without arrhythmia).
- Hemodynamic instability despite fluids and vasopressors.
- Patient is peri-arrest or in cardiac arrest.
- Potassium readings may be falsely elevated in DKA.
Preferred Administration Method
- Avoid bolus ("Crash Cart") bicarbonate due to hypertonicity.
- Recommended approach: mix 3 amps of bicarbonate in 1L D5W and infuse at 100–150cc/hour until stabilization.
Recommendations / Advice
- Do not routinely administer sodium bicarbonate in DKA.
- Reserve bicarbonate for life-threatening situations with severe acidosis and complicating features.
- Use diluted, controlled infusions rather than concentrated boluses for safer administration.