Alkali therapy of diabetic ketoacidosis: Biochemical, physiologic, and clinical perspectives

Riley, Louis J.; Cooper, M.; Narins, Robert G.

doi:10.1002/dmr.5610050801

Cited by 21 publications

(10 citation statements)

References 37 publications

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“…Based on data from the physiology laboratory coupled with animal and human data, it was believed bicarbonate could improve insulin sensitivity, improve cardiac and pulmonary function, decrease the work of breathing, decrease malignant arrhythmias, and reduce the duration of coma. 50,51 Multiple studies, however, have failed to show any benefit from bicarbonate in DKA and have suggested its use may actually be detrimental. 50,[52][53][54][55] In theory, bicarbonate therapy in DKA should allow pH to rise more rapidly and for metabolic homeostasis to be regained sooner.…”

Section: Diabetic Keto Acidosismentioning

confidence: 99%

Selected Controversies in Cardiopulmonary Resuscitation

White

Himes²,

Rouhani³

et al. 2001

Seminars in Respiratory and Critical Care Medicine

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Cardiopulmonary resuscitation (CPR) is performed frequently by paramedics, emergency department personnel, and inpatient physicians. Unfortunately, after more than 40 years of practice and study, there are still many controversies and unresolved treatment issues. This article focuses on four current controversies in CPR: (1) the role of end-tidal CO2 (ETCO2) detection, (2) the use of bicarbonate, (3) whether epinephrine is the optimal alpha agonist, and (4) whether amiodarone should replace lidocaine as the initial antiarrhythmic of choice in the treatment of ventricular fibrillation.

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Section: Diabetic Keto Acidosismentioning

confidence: 99%

Selected Controversies in Cardiopulmonary Resuscitation

White

Himes²,

Rouhani³

et al. 2001

Seminars in Respiratory and Critical Care Medicine

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“…Much of the perceived benefit in acute reversal of severe acidemia is only based on animal and experimental studies, which demonstrated weakened end-organ response to catecholamines at pH < 7.2, with bradycardia, negative inotropism, impaired cardiac output, peripheral vasodilatation, and refractory hypotension [53]. Therefore, even though the clinical harm with bicarbonate treatment is merely an association (and not causation), the lack of clinical benefits does not justify its routine use especially in children.…”

Section: Discussionmentioning

confidence: 99%

Bicarbonate in diabetic ketoacidosis - a systematic review

Chua

Schneider

Bellomo

2011

Ann. Intensive Care

115

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ObjectiveThis study was designed to examine the efficacy and risk of bicarbonate administration in the emergent treatment of severe acidemia in diabetic ketoacidosis (DKA).MethodsPUBMED database was used to identify potentially relevant articles in the pediatric and adult DKA populations. DKA intervention studies on bicarbonate administration versus no bicarbonate in the emergent therapy, acid-base studies, studies on risk association with cerebral edema, and related case reports, were selected for review. Two reviewers independently conducted data extraction and assessed the citation relevance for inclusion.ResultsFrom 508 potentially relevant articles, 44 were included in the systematic review, including three adult randomized controlled trials (RCT) on bicarbonate administration versus no bicarbonate in DKA. We observed a marked heterogeneity in pH threshold, concentration, amount, and timing for bicarbonate administration in various studies. Two RCTs demonstrated transient improvement in metabolic acidosis with bicarbonate treatment within the initial 2 hours. There was no evidence of improved glycemic control or clinical efficacy. There was retrospective evidence of increased risk for cerebral edema and prolonged hospitalization in children who received bicarbonate, and weak evidence of transient paradoxical worsening of ketosis, and increased need for potassium supplementation. No studies involved patients with an initial pH < 6.85.ConclusionsThe evidence to date does not justify the administration of bicarbonate for the emergent treatment of DKA, especially in the pediatric population, in view of possible clinical harm and lack of sustained benefits.

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“…Metabolic alkalosis can occur following excessive administration of alkali, as occurs in the milk-alkali syndrome,80 unintentional ingestion,81 ‘overshoot alkalosis’ following bicarbonate treatment for metabolic acidosis,82 or after massive transfusion of citrate containing blood products, as in exchange transfusion 83…”

Section: Metabolic Alkalosismentioning

confidence: 99%

A clinical approach to paediatric acid–base disorders

Carmody

Norwood

2012

Postgraduate Medical Journal

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Acid-base disorders are common in pediatric patients. We present a simple methodology for assessing both simple and complex acid-base disorders that is applicable to patients of all ages, and focus specifically on the usefulness of this approach in the pediatric patient. The application of four simple rules in sequence will define even the most complicated acid-base disturbance. However, because acid-base disorders are manifestations of systemic disorders, the primary value of characterizing them is that each generates a unique differential diagnosis. For each of the cardinal acid base disorders, the common and clinically-relevant causes in pediatric patients are explored. Additional diagnostic tools (including the serum anion gap, the delta-delta, the alveolar-arterial gradient, urine anion gap, and urine chloride), certain easily-recalled mnemonics, and empiric rules of thumb are also useful in specific situations. The treatment of acid-base disturbances is also considered, though treatment is generally best directed at the underlying disorder.

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Alkali therapy of diabetic ketoacidosis: Biochemical, physiologic, and clinical perspectives

Cited by 21 publications

References 37 publications

Selected Controversies in Cardiopulmonary Resuscitation

Selected Controversies in Cardiopulmonary Resuscitation

Bicarbonate in diabetic ketoacidosis - a systematic review

A clinical approach to paediatric acid–base disorders

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