EBQ:Sodium Bicarbonate use in DKA

Clinical Question

What is the utility of sodium bicarbonate in the treatment of Diabetic Ketoacidosis?


  • No evidence supports the use of sodium bicarb in DKA, with a pH >6.9
  • However, no studies have been performed for patients with pH <6.9 and the most recent ADA guidelines recommend it for patients with pH <7.1


Sodium bicarbonate alkalizes the blood by binding H+ and converting it to water and CO2. It previously was used by some physicians in the treatment of DKA.

Pro Argument

The most recent American Diabetes Association guidelines[1] note that:

  • "Bicarbonate use in DKA remains controversial"[2]
  • "Prospective randomized studies have failed to show either beneficial or deleterious changes in morbidity or mortality with bicarbonate therapy in DKA patients with pH between 6.9 and 7.1"[3]
  • "No prospective randomized studies concerning the use of bicarbonate in DKA with pH values <6.9 have been reported. Given that severe acidosis may lead to a myriad of adverse vascular effects, it seems prudent that for adult patients with a pH <6.9, 100 mmol sodium bicarbonate be added to 400 ml sterile water and given at a rate of 200 ml/h. In patients with a pH of 6.9–7.0, 50 mmol sodium bicarbonate is diluted in 200 ml sterile water and infused at a rate of 200 ml/h. No bicarbonate is necessary if pH is >7.0."[4]
  • "In the pediatric patient, there are no randomized studies in patients with pH <6.9. If the pH remains <7.0 after the initial hour of hydration, it seems prudent to administer 1–2 mEq/kg sodium bicarbonate over the course of 1 h. This sodium bicarbonate can be added to NaCl, with any required potassium, to produce a solution that does not exceed 155 mEq/l sodium. No bicarbonate therapy is required if pH is ≥7.0 (30,31)."[5]

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 [6]

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[7]

Trial 3

Review Article included patients with PH<7

  • Results: Sodium Bicarbonate didn't decrease time to improvement nor to hospital discharge[8]

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 [9]

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 [10]

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 [11]

Trial 7

RCT done for 38 patients 16 patients in NaHco3 Group had delayed ketone clearance and no significant difference in blood glucose level[12]

Trial 8

RCT of 7 Patients 3 of them received NaHco3 and showed delay ketones clearance for 6 hours compard with control[13]


  1. "Hyperglycemic Crises in Diabetes" doi: 10.2337/diacare.27.2007.S94 Diabetes Care January 2004 vol. 27 no. suppl 1 s94-s102
  2. Barnes HV, Cohen RD, Kitabchi AE, Murphy MB: When is bicarbonate appropriate in treating metabolic acidosis including diabetic ketoacidosis? In Debates in Medicine. Gitnick G, Barnes HV, Duffy TP, et al., Eds. Chicago, Yearbook, 1990, p. 172
  3. Morris LR, Murphy MB, Kitabchi AE: Bicarbonate therapy in severe diabetic ketoacidosis. Ann Int Med 105:836–840, 1986
  4. "Hyperglycemic Crises in Diabetes" doi: 10.2337/diacare.27.2007.S94 Diabetes Care January 2004 vol. 27 no. suppl 1 s94-s102
  5. "Hyperglycemic Crises in Diabetes" doi: 10.2337/diacare.27.2007.S94 Diabetes Care January 2004 vol. 27 no. suppl 1 s94-s102
  6. Morris LR, Murphy MB, Kitabchi AE. Bicarbonate therapy in severe diabetic ketoacidosis. Ann Intern Med. 1986 Dec;105(6):836-40. PubMed PMID: 3096181
  7. 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
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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.

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