2025 Southeastern Residency Conference

Title: Evaluating the Safety and Efficacy of Bicarbonate Use in Moderate-to-Severe Diabetic Ketoacidosis

Authors: John Ethan Young, Ashley Crisler, Bianca Rivera-Ramirez, McKenzie Hodges

Objective: To evaluate the effects of sodium bicarbonate therapy on the resolution of DKA and its associated outcomes
 
Self-Assessment Question: Which of the following is not characteristic of diabetic ketoacidosis? (A) Hyperglycemia (B) Metabolic alkalosis (C) Ketosis (D) Metabolic acidosis

Background: Diabetic ketoacidosis (DKA) is an acute, life-threatening complication of diabetes characterized by hyperglycemia, metabolic acidosis, and elevated ketone levels. While the mainstays of DKA treatment include insulin therapy, fluid resuscitation, and electrolyte correction, the use of sodium bicarbonate to treat acidosis remains controversial. The American Diabetes Association (ADA) 2024 guidelines recommend considering sodium bicarbonate only in cases of severe acidosis (pH <6.9), but its routine use varies widely across institutions. Preliminary evidence from randomized studies has shown no significant improvement in morbidity or mortality with sodium bicarbonate therapy in DKA patients with pH levels between 6.9 and 7.1. However, there remains a gap in the literature regarding its impact on time to DKA resolution, which this study seeks to address. By clarifying the role of sodium bicarbonate in DKA management, this study aims to provide insight into optimizing treatment strategies and minimizing unnecessary interventions in the care of DKA patients.
 
Methods: A retrospective chart review was performed on adult patients treated for diabetic ketoacidosis (DKA) at Piedmont Columbus Regional Midtown between January 1, 2023 and December 31, 2023. Patients had to be 18 years of age or older and have clinical evidence of moderate-to-severe DKA. Patients that met these parameters were divided into two groups based on the administration of a sodium bicarbonate infusion. Patients were excluded if they presented with euglycemic DKA or if their insulin infusion was terminated prior to DKA resolution. The primary objective was time to DKA resolution. Secondary objectives included duration of insulin infusion, recurrence of acidosis, incidence of hypokalemia, hospital length of stay, and ICU length of stay. An independent t-test was used for the primary outcome, as well as the secondary outcomes of insulin infusion duration and length of stay, while a Chi Square Test was used to evaluate the recurrence of acidosis and incidence of hypokalemia.
 
Results: The patients receiving bicarbonate (n=32) had an average time to DKA resolution of 21.9 hours, while the patients receiving the standard of care (n=31) had an average time of 18.4 hours. Additionally, there was no difference seen for the secondary outcomes of insulin infusion duration [23.4 h vs 20.3 h], recurrence of acidosis [15.6% vs 3.2%], incidence of hypokalemia [65.6% vs 51.6%], and ICU length of stay [4.6 d vs 3.3 d]. There was a statistically significant difference for incidence of moderate hypokalemia [28.1% vs 6.5%] and hospital length of stay [10.3 d vs 5.2 d].
 
Conclusion: This study demonstrates that bicarbonate therapy is not efficacious in the management of DKA and may increase the incidence of moderate hypokalemia, risk of fluid overload, and potentially contribute to longer hospital length of stay. In conclusion, bicarbonate therapy should be seldom used for DKA, and the decision should be made by weighing the risks and benefits.