Use of bicarbonate in adults with diabetic ketoacidosis
Date First Published:
November 13, 2003
Last Updated:
July 1, 2005
Report by:
Stewart Teece, Clinical Research Fellow (Emerge)
Search checked by:
Roger Hessels, Emerge
Three-Part Question:
In [adults with diabetic ketoacidosis and significant acidaemia] is [the additional administration of iv bicarbonate better than standard fluid resuscitation] give [more rapid improvement of biochemical parameters and an increased survival]
Clinical Scenario:
A 28 year old diabetic attends having been found unrusable by friends. Initial examination shows her to be GCS 5/15 with a BM measurement of high. Blood gases show her to have a pH of 7.02 and a blood sugar comes back at 41mmol/l and her urine shows three plus ketones. You begin treatment with insulin and IV fluids and contact ITU for an opinion on airway management and ventilation. The ITU registrar asks you to start a bicarbonate infusion while he is on the way down. You are unsure if this is beneficial and decide to find evidence on who is right.
Search Strategy:
Medline 1966-November week 1 2003 using the OVID interface
Search Details:
[{exp DIABETIC KETOACIDOSIS/ OR keto-acidosis.af OR ketoacidosis.af. OR dka.af.} AND {exp BICARBONATES/ OR bicarbonate.af. OR nahco3.af. OR (hydrogen adj5 carbonate).af.}]LIMIT to human AND English language
Outcome:
327 papers found 5 appeared relevant to the three part question
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Treatment of Severe Diabetic Ketoacidosis A Comparative Study of Two Methods Lutterman JA, Adriaansen AAJ & van't Laar A 1979 Netherlands | 24 patients in DKA (ph<7.10). 12 recieved high dose insulin and 167 mmol bicarbonate plus iv fluid. 12 recieved low dose insulin and iv fluid. | PRCT | plasma glucose | No statistical difference at 8hours | Randomization by year of attendance= ?change in skills of staff small numbers results complicated by differing dose insulin |
| pH | both groups all reached>7.3 within 10h.No significant difference in mean pH between 2 groups at an time | ||||
| Survival | 1 patient in fluids group died. 69yo with 12 hour coma prior to treatment | ||||
| Sodium Bicarbonate Therpy in Severe Diabetic ketoacidosis Lever E & Jaspan JB 1983 USA/UK | 73 patients in two hospitals with 85 episodes DKA (pH<7.1) 73 episodes recieved a mean of 130 mmol of bicarbonate. 22 without. Otherwise standard treatment. |
Retrospective case note review. | Mean change in pH/hour | bicarb 0.038+/-0.013 no bicarb 0.032 +/-0.005 (n/s) | Retrospective numbers small |
| mean change glucose mmol/l/hr | bicarb 3.3 +/-1.1 no bicarb 4.1 +/- 1.2 | ||||
| mean time to GCS 15 (hours) | bicarb 4+/-1 No bicarb 4+/- 1.5 (n/s) | ||||
| mean change bicarbonate mmol/l/hr | bicarb 0.9+/-0.3 no bicarb 1.1 +/- 0.3 | ||||
| Metabolic effects of bicarbonate in the treatment of diabetic ketoacidosis Hale PJ, Crase J, Nattrass M 1984 UK | 38 patients with DKA (pH<7.2).16 bicarbonate 150meq + fluid/insulin.16 fluid only. 6 excluded due to starting glucose. | PRCT | Mean rise in pH at 120 mins | bicarb 7.06 to 7.23 no bicarb 7.05 to 7.12 (p<0.01) | small numbers study lasted only 120 minutes |
| Level of ketones,pyruvate and lactete | Significantly lower (p<0.05) in no bicarb group | ||||
| Bicarbonate therapy in Severe Diabetic Ketoacidosis Morris LR, Murphy MB, Kitabchi AE 1986 USA | 21 patient is DKA (pH 6.9-7.14). 10 bicarbonate/fluids/insulin. 11 fluids/insulin | PRCT | time for PH to reach 7.3 | bicarb 13.1+/-2.5h no bicarb 15.6+/-2.5h(n/s) | small numbers control group sicker at baseline |
| rate of change in pH, ketones,bicarbonate levels | no significant difference at 8 hours | ||||
| Does bicarbonate therapy improve the management of severe diabetic ketoacidosis Viallin A,Zeni F,Lafond P, Venet C, Tardy B, Pages Y, Bertrand JC 1999 France | 39 DKA pts (pH<7.1).24 bicarbonat/fluid/insulin. 15 fluid/insulin | Retrospective review of case notes | Time to pH>7.3 | Bicarb 8+/-1h No bicarb 8+/-1.2h | Small retrospective study |
| PaCO2,lactate,chloride,creatinine,urea,osmolality,respiratory rate,heart rate,GCS arterial pressure | No significant difference |
Author Commentary:
All the studies are small which may explain the lack of statistical significance. However all contain graphs showing the variables under investigation over time all of which are similar in pattern. The impression these give is that bicarbonate gives an initial rise in pH as one would expect from it's buffer properties, however the use of bicarbonate seems to have a detrimental affect on the breakdown of the fatty acids causing the acidosis hence initially treating symptom but not cause. In all groups rehydration/insulin seem to settle the source of acidosis over time.
Bottom Line:
There appears to be no advantage to the use of intravenous bicarbonate in diabetic ketoacidosis.
References:
- Lutterman JA, Adriaansen AAJ & van't Laar A. Treatment of Severe Diabetic Ketoacidosis A Comparative Study of Two Methods
- Lever E & Jaspan JB. Sodium Bicarbonate Therpy in Severe Diabetic ketoacidosis
- Hale PJ, Crase J, Nattrass M. Metabolic effects of bicarbonate in the treatment of diabetic ketoacidosis
- Morris LR, Murphy MB, Kitabchi AE. Bicarbonate therapy in Severe Diabetic Ketoacidosis
- Viallin A,Zeni F,Lafond P, Venet C, Tardy B, Pages Y, Bertrand JC. Does bicarbonate therapy improve the management of severe diabetic ketoacidosis