Bicarbonate in diabetic ketoacidosis - a systematic review

Horng Ruey Chua,Antoine Schneider,Rinaldo Bellomo

doi:10.1186/2110-5820-1-23

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.

Highlights

Diabetic ketoacidosis (DKA) is a serious medical emergency resulting from relative or absolute insulin deficiency and the unopposed action of counter-regulatory hormones, such as glucagon, cortisol, and catecholamines [1]
Summary of evidence We conducted a systematic review of the literature, comparing additional use of bicarbonate infusion versus the usual treatment with insulin and hydration, in pediatric and adult patients with DKA
We have found marked heterogeneity and no clear evidence, with regards to the threshold for, concentration, amount, and timing of bicarbonate administration

Summary

Introduction

Diabetic ketoacidosis (DKA) is a serious medical emergency resulting from relative or absolute insulin deficiency and the unopposed action of counter-regulatory hormones, such as glucagon, cortisol, and catecholamines [1]. Impaired tissue perfusion due to volume contraction and the adrenergic response to the often severe underlying precipitating illness result in lactate production [4]. Experimental studies suggest that metabolic acidemia can impair myocardial contractility, reduce cardiac output, affect oxyhemoglobin dissociation and tissue oxygen delivery, inhibit intracellular enzymes, such as phosphofructokinase, alter cellular metabolism, and result in vital organ dysfunction [9,10,11,12]. The target of therapy in DKA has historically placed importance on the rapid reversal of acidemia, in addition to the correction of dehydration and insulin deficiency

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