hey recos xer SEL riah here and I posed this question online a few weeks ago should we give sodium bicarbonate in diabetic keto acidosis and as you can imagine I got some really polarizing responses to it but let me just set this up with a hypothetical patient adult female patient with type 1 diabetes militus ran out of her insulin and presents with dka here's her initial Labs pH of 6.6 a serum bicarbonate of 1.5 a CO2 of 19 an anion gap of 29 a potassium of 7.2 a glucose reading greater than a th000 respiratory rate in the 50s this patient is obviously kousal breathing and hypotensive with a blood pressure of 90s over 50s and a GCS of 9 completely altered patient now I presented that exact scenario on both X which used to be called Twitter and on my YouTube channel and as you can see the majority of people actually said yes but the people who were actually responding were pretty strong in their intent of no we should not give bicarbonate now the purists among us might say for physiologic reasons we should not be giving bicarbonate because it's only going to make the patient more acidotic the evidencebased medicine answer is there's no highlevel evidence to give bicarbonate here's my responses to that so from the physiologic standpoint yes it's true if we give bicarbonate to patients that will bind with hydrogen and become H2O as well as carbon dioxide and when you have a patient that's breathing in the 50s and already acidotic you are potentially going to make them more acidotic but how many things have made physiologic sense in medicine that only when it came time to study them it turned out that it wasn't the case and that's because humans are complex it's not as simple as equations that we learned in school now as far as the lack of evidence for sodium bicarbonate here's my answer an absence of evidence is not evidence of absence with that being said keys to all dka patients insulin insulin and more insulin they need insulin we need to give them time we want to use balanced crystalloids not normal saline because normal saline can make more acidotic and then it depends on the mental status of the patient this patient has a GCS of N I would be concerned about vomiting and aspiration so I would probably avoid Bap I would probably do something like high flow nasal canula as a BAP light to help with work of breathing as well as help them blow off some of that CO2 by trying to improve some of their minute ventilation I do not routinely use sodium B carbonate in the management of my dka patients however there are some scenarios where I consider it and I do use it so if I have a patient with a pH of less than 6.9 now that number by itself will not push me to use sodium bicarbonate they have to have one or more of these things I'm about to list hyper calmia with or without arrhythmias which in this patient her potassium was 7.2 and I'm not saying it truly was 7.2 it's probably falsely ated but when it comes down to it I'm going to treat the patient in front of me hemodynamic instability even with fluids and pressors so this patient had already gotten 2 liters of lactated ringers and still was remaining hypotensive to the point that we were starting a norepinephrine drip to support the hemodynamics and I think when you have a per arrest or Cardiac Arrest patient all bets are off at that point I'm going to do whatever I can to buy myself a little bit more time to get that patient back now what is the best way to give sodium bicarb now most people think when I'm posing that question that I'm implying that we should be giving Crash Cart bicarbonate which is 88.4% sodium bicarbonate this is the equivalent of 6% normal saline it's a 2,000 Milli ooms per liter solution that you're giving now we don't have this readily available to us in the United States but there are a lot of places in Europe that have this kind of half concentration sodium bicarbonate which is 1,000 millios per liter which is 3% normal saline right it's like giving hyper tonics to a patient with increase in a cranial pressure the way I like to do it is I like to take 3 amps of bicarb and put it in one liter of D5W this is the equivalent of 300 millios per liter right this is like doing 9% normal saline it's a more isotonic solution until I have my patient more stabilized and looking better giving my insulin time my lactated ringer time and then I turn it off should we give sodium bicarbonate and dka I'm going to tell you in 95% of the cases the answer is no if the pH is less than 6.9 and they have any one of these things hyperemia with and without arrhythmias hemodynamic instability even with fluids and pressors or the patient is par arrest or Cardiac Arrest then I would consider giving bicarbonate but not in the way that we typically do which is Crash Cart bicarbonate I would mix my 3 amps of bicarbonate put it in one liter of D5W and I would run that at 100 to 150 CC's per hour until my patient is a little more stabilized so there you have it would love to hear your thoughts comments and questions I hope this kind of stirred some debate amongst you in the room and I'm sorry I couldn't be there but Haney thank you for the invitation and I hope this gets some controversy going in the room oh