Bicarbonate in diabetic ketoacidosis - a systematic review

Abstract

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.

Traditional Acid-Base Analysis

“…Many animal studies have demonstrated decreases in cellular and cerebrospinal fluid pH after bicarbonate therapy. [45][46][47][48] Bicarbonate therapy has also been associated with increases in blood lactate concentration in studies of lactic acidosis, hemorrhagic shock, and DKA. 43,46,49,50 The exact mechanism for this response is not known, but left shifting of the oxygenhemoglobin dissociation curve because of increases in blood pH may play a role.…”

“…This is particularly relevant to animals with lactic acidosis or DKA, where bicarbonate therapy has been associated with no improvement in outcome or clinical deterioration despite severe acidemia. 44,48 It is likely that bicarbonate therapy will be beneficial in the treatment of diseases causing bicarbonate loss, such as chronic kidney disease and diarrhea (an uncommon cause of metabolic acidosis in small animal patients). 51,52 The role of bicarbonate therapy in the management of patients with acute kidney injury (AKI) is less well defined.…”

Treatment of Pediatric Diabetic Ketoacidosis in Canada: A Review of Treatment Protocols from Canadian Pediatric Emergency Departments

“…4 Bicarbonate administration may cause harm by decreasing delivery of tissue oxygen and, paradoxically, causing cerebrospinal fluid acidosis during treatment for DKA. 20 Further research is needed to clarify the role bicarbonate administration plays in severe pediatric DKA to guide future treatment protocols.…”

Вплив Альтерації Гомеостазу Глюкози На Водно-Електролітний Баланс Та Кислотно-Основний Стан У Пацієнтів Із Цукровим Діабетом

“…Застосування олужнюючих розчинів зазвичай не потрібне, оскільки інсулін знижує швидкість утво-рення кетокислот, а окислення кетоаніонів веде до утворення бікарбонату. Але є певні ситуації, при яких застосовують лужні розчини, зокрема при ви-сокому ризику розвитку набряку головного мозку в дітей [9,27].…”