EBQ:Sodium Bicarbonate use in DKA
Clinical Question
Should Sodium Bicarbonate be used to treat Diabetic Ketoacidosis ?
Background
Sodium bicarbonate is a solution which help alkalanizing the blood by binding the H+ and converting it to water and Co2. Many Physicians use it to treat DKA, but based on what ? Is there any evidence supporting its use ?
Pro Argument
Looking for any studies supporting its use ...
Con Argument
Trial 1
21 patients underwent RCT
- 10 patients (PH 6.9-7.14) received NaHco3
- 11 patients in the control group
Results: No differences in Glucose level, bicarb level nor PH [1]
Trial 2
Prospective, Randomized, Blinded and cross over study included 14 patients
- HCO3 level <17
- Received Sodium Bicarbonate 2mmol/kg over 15 minutes
Results: Sodium Bicarbonate decreased Ionized Calcium, increased Paco2 and didn't improve hemodynamics[2]
Trial 3
Review Article included patients with PH<7
- Results: Sodium Bicarbonate didn't decrease time to improvement nor to hospital discharge[3]
Trial 4
Retrospective Study of 39 patients with PH<7.1
- 24 patients received sodium bicarbonate
- 15 patients control
- Results: More Hypokalemia in the experiment group, No differences in clinical or biochemical parameters [4]
Trial 5
Retrospective of 147 pediatric DKA cases with PH<7.15
- 90 patients received bicarbonate
- 57 patients contol
Results:Bicarbonate didn't improve clinical outcomes, but hospitalization was prolonged with the bicarb group [5]
Trial 6
Systematic Review of 44 studies Results: Bicarbonate use increased cerebral edema and prolonged hospitalization in pediatrics age group and increased ketosis and need for potassium supplementation [6]
Trial 7
RCT done for 38 patients 16 patients in NaHco3 Group had delayed ketone clearance and no significant difference in blood glucose level[7]
Trial 8
RCT of 7 Patients 3 of them received NaHco3 and showed delay ketones clearance for 6 hours compard with control[8]
Conclusion
- No Evidence supports its use for PH>6.9
- No studies done for PH<6.9
- American Diabetic Association Recommends giving 100 mmol NaHco3 in 400 Normal saline with 20 Meq potassium chloride over 2 hours[9]
Sources
- ↑ Morris LR, Murphy MB, Kitabchi AE. Bicarbonate therapy in severe diabetic ketoacidosis. Ann Intern Med. 1986 Dec;105(6):836-40. PubMed PMID: 3096181
- ↑ Cooper DJ, Walley KR, Wiggs BR, Russell JA. Bicarbonate does not improve hemodynamics in critically ill patients who have lactic acidosis. A prospective, controlled clinical study. Ann Intern Med. 1990 Apr 1;112(7):492-8. PubMed PMID: 2156475
- ↑ 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. PubMed PMID: 23737516.
- ↑ Viallon A, Zeni F, Lafond P, Venet C, Tardy B, Page Y, Bertrand JC. Does bicarbonate therapy improve the management of severe diabetic ketoacidosis? Crit Care Med. 1999 Dec;27(12):2690-3. Review. PubMed PMID: 10628611.
- ↑ Green SM, Rothrock SG, Ho JD, Gallant RD, Borger R, Thomas TL, Zimmerman GJ. Failure of adjunctive bicarbonate to improve outcome in severe pediatric diabetic ketoacidosis. Ann Emerg Med. 1998 Jan;31(1):41-8. Review. PubMed PMID: 9437340.
- ↑ 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. PubMed PMID: 21906367; PubMed Central PMCID: PMC3224469.
- ↑ Hale PJ, Crase J, Nattrass M. Metabolic effects of bicarbonate in the treatment of diabetic ketoacidosis. Br Med J (Clin Res Ed). 1984 Oct 20;289(6451):1035-8. PubMed PMID: 6091840; PubMed Central PMCID: PMC1443021.
- ↑ Okuda Y, Adrogue HJ, Field JB, Nohara H, Yamashita K. Counterproductive effects of sodium bicarbonate in diabetic ketoacidosis. J Clin Endocrinol Metab. 1996 Jan;81(1):314-20. PubMed PMID: 8550770.
- ↑ Diabetes Care July 2009 vol. 32 no. 7 1335-1343