Bicarb in Diabetic Ketoacidosis (DKA): One Minute Journal Club

This is a one minute journal club. This is not medical advice. The full breakdown in below this snippet.
Read the data for yourself.
Should we provide our DKA patients with sodium bicarbonate (bicarb) to improve their pH?
We want to make the numbers pretty.
We want to fix the acidosis faster, but does this work?
The first thing people often forget is that bicarb is metabolized into CO2.
If the patient is huffing and puffing, providing bicarb is only going to make their work of breathing harder.
A systematic review and meta-analysis of 44 papers was published in 2011.
These patients all had a mean pH of less that 7.05.
There was no benefit in any of their outcomes.
More recently, a 2013 study. looked 86 at patients with a pH of less than 6.9 retrospectively.
Did giving bicarb resolve their DKA faster? Nope.
A 2018 review in a diabetes journal confirmed the prior statements.
If your patient has life-threatening hyperkalemia you may have an argument.
I know we all feel like we need to do something when we get these sick patients, but this is not substantiated in the evidence.
Since we are not going to improve outcomes with bicarbonate, then why are we even checking check venous blood gases or worse, painful arterial blood gases?

Don’t give bicarb to your patients with respiratory acidosis. CLICK HERE to learn more.
If you want to learn about bicarb in blood gases and in serum, CLICK HERE.

Bicarb in Diabetic Ketoacidosis (DK...
Bicarb in Diabetic Ketoacidosis (DKA): One Minute Journal Club

Podcast Transcript for Bicarb in DKA

Welcome to the Saving Lives Podcast.  This is not medical advice. Check out the full post on my website where I have links to all these articles directly so you could double check my work. Read the data for yourself.

Relating to my colleagues in the ED

My friends in the emergency department have an extremely tough job. They take care of a myriad of patients with differing pathologies and complaints. Keeping up with the literature on things ranging from pediatrics to orthopedics to general medicine must be challenging. I understand that it is difficult to stay up to date with everything. Especially when so many things don’t necessarily have great data and sometimes doing what you’ve always done comes to play.

I often get asked questions about giving patients who are in diabetic ketoacidosis, aka DKA, sodium bicarbonate which we call bicarb for short. By definition, these patients are acidotic. They have a serum bicarb that is in the teens or single digits, their blood glucose is what it is, and they are huffing and puffing with that textbook ketone smell. The common practice is to obtain an ABG or VBG. I personally do not recommend obtaining either. After all, once you have the BMP and a history you should know what is going on. But in the face of this acidosis, many want to provide their patients with sodium bicarb to attempt to correct this. But is it the right thing to do? 

The Super Sick DKA Patients: Should we give them bicarb?

I will provide a disclaimer that when the pH is severely low and the patient is hyperkalemic and hemodynamically unstable, all bets are off. You do what you gotta do to save that patients life. After all, you cannot enroll those patients in a clinical trial. Remember that bicarb is not benign. In a patient with hypokalemia it will make the patient even more hypokalemic as there will be a shift of potassium from the extracellular space into the intracellular space. In addition, it causes hypocalcemia. 
Also keep in mind that when we provide bicarb to patients, it gets metabolized to CO2. That CO2 needs to leave the body somehow and we breathe it away. But DKA patients are already working hard to blow down their CO2 in an attempt to compensate for their metabolic acidosis. So are you really helping or worsening their burden?
But enough of these scenarios. You all come to me with data so I will bring the data. The bottom line is that you should not be using bicarb pushes nor drips in DKA patients.
Again, Should we provide our DKA patients with sodium bicarbonate (bicarb) to improve their pH?
We want to make the numbers pretty.
We want to fix the acidosis faster, but does this work?

Looking at the data for giving DKA patients IV bicarb

A systematic review and meta-analysis of 44 papers was published in 2011. This review is completely free for you to download. If you are an anti-bicarb in DKA person and your colleagues are pro-bicarb, I suggest you print this bad boy out and hand it to them. It’s hard to imagine but there aren’t many RCTs on the matter. Out of these 44 papers, only 3 were RCTs in adults that compared bicarb to no bicarb.
These patients all had a mean pH of less that 7.05. 

The primary outcome was duration of hospitalization. There was no difference between the two groups. Giving bicarb did not get patients out of the hospital faster. Amongst the secondary outcomes they looked at the correction of acidosis. Well, there was no benefit in the resolution of the acidosis in these patients. The resolution of ketosis took longer in the bicarb group. There was no improvement in glycemic control nor insulin requirement. Some provide bicarb for hemodynamic parameters. Well, there was no improvement here either.  So you’re saying to yourself right now, “well, Eddy, these data are over a decade old!”. When one is searching for studies, you should look at PubMed, not google. If you search google you will find my website and then I’ll point you to the studies.

More recently, a 2013 study. looked 86 at patients with a pH of less than 6.9 retrospectively. Once again, the sicker patients. This study is behind a paywall so you have to trust me here.
Did giving bicarb resolve their DKA faster? Nope. Did they get out of the hospital faster? Nope. The bicarb patients required more insulin and fluid at the end of the day.

The World Journal of Diabetes published a review in 2018 that reiterated the prior findings. They stated that “the bulk of the data argue against significant benefit in important clinical outcomes and suggest possible adverse effects with the use of bicarbonate”. 

The endocrinology team at Emory published a nice review on the management of DKA where they addressed bicarb. Here, they state “Although no studies have looked at the effect of bicarbonate therapy in patients with severe acidosis, because of the potential risk of reduced cardiac contractility and arrhythmias, clinical guidelines recommend the administration of 50–100 mmol of sodium bicarbonate as an isotonic solution (in 400 mL of water) until pH is > 6.9.”

If your patient has immediate life-threatening issues, you may have an argument. I know we all feel like we need to do something when we get these sick patients, but this is not substantiated in the evidence.
Since we are not going to improve outcomes with bicarbonate, then why are we even checking check venous blood gases or worse, painful arterial blood gases? That’s a question I leave for you.

Citations for Bicarb in DKA

Chua HR, Schneider A, Bellomo R. Bicarbonate in diabetic ketoacidosis – a systematic review. Ann Intensive Care. 2011 Jul 6;1(1):23. doi: 10.1186/2110-5820-1-23. PMID: 21906367; PMCID: PMC3224469.
Link to Article
Link to FULL FREE PDF

Duhon B, Attridge RL, Franco-Martinez AC, Maxwell PR, Hughes DW. Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis. Ann Pharmacother. 2013 Jul-Aug;47(7-8):970-5. doi: 10.1345/aph.1S014. Epub 2013 Jun 4. PMID: 23737516.
Link to NOT FREE Article

Patel MP, Ahmed A, Gunapalan T, Hesselbacher SE. Use of sodium bicarbonate and blood gas monitoring in diabetic ketoacidosis: A review. World J Diabetes. 2018 Nov 15;9(11):199-205. doi: 10.4239/wjd.v9.i11.199. PMID: 30479686; PMCID: PMC6242725.
Link to Article
Link to FULL FREE PDF

Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am. 2017 May;101(3):587-606. doi: 10.1016/j.mcna.2016.12.011. PMID: 28372715; PMCID: PMC6535398.
Link to Article
Link to FULL FREE PDF

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