Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Diabetes. Nov 15, 2018; 9(11): 199-205
Published online Nov 15, 2018. doi: 10.4239/wjd.v9.i11.199
Use of sodium bicarbonate and blood gas monitoring in diabetic ketoacidosis: A review
Mit P Patel, Ali Ahmed, Tharini Gunapalan, Sean E Hesselbacher
Mit P Patel, Ali Ahmed, Tharini Gunapalan, Sean E Hesselbacher, Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA 23501, United States
Sean E Hesselbacher, Medicine Service, Hampton Veterans Affairs Medical Center, Hampton, VA 23667, United States
Author contributions: All authors equally contributed to this paper with literature review and analysis, drafting and critical revision and editing, and final approval of the final version.
Conflict-of-interest statement: No potential conflicts of interest. No financial support.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Sean E Hesselbacher, FCCP, MD, Assistant Professor, Medicine Service, Hampton Veterans Affairs Medical Center, 100 Emancipation Drive, Hampton, VA 23667, United States.
Telephone: +1-757-7229961 Fax: +1-757-7283187
Received: July 22, 2018
Peer-review started: July 22, 2018
First decision: August 9, 2018
Revised: August 30, 2018
Accepted: October 9, 2018
Article in press: October 9, 2018
Published online: November 15, 2018

Diabetic ketoacidosis (DKA) is a severe and too-common complication of uncontrolled diabetes mellitus. Acidosis is one of the fundamental disruptions stemming from the disease process, the complications of which are potentially lethal. Hydration and insulin administration have been the cornerstones of DKA therapy; however, adjunctive treatments such as the use of sodium bicarbonate and protocols that include serial monitoring with blood gas analysis have been much more controversial. There is substantial literature available regarding the use of exogenous sodium bicarbonate in mild to moderately severe acidosis; the bulk of the data argue against significant benefit in important clinical outcomes and suggest possible adverse effects with the use of bicarbonate. However, there is scant data to support or refute the role of bicarbonate therapy in very severe acidosis. Arterial blood gas (ABG) assessment is an element of some treatment protocols, including society guidelines, for DKA. We review the evidence supporting these recommendations. In addition, we review the data supporting some less cumbersome tests, including venous blood gas assessment and routine chemistries. It remains unclear that measurement of blood gas pH, via arterial or venous sampling, impacts management of the patient substantially enough to warrant the testing, especially if sodium bicarbonate administration is not being considered. There are special circumstances when serial ABG monitoring and/or sodium bicarbonate infusion are necessary, which we also review. Additional studies are needed to determine the utility of these interventions in patients with severe DKA and pH less than 7.0.

Keywords: Diabetic ketoacidosis, Sodium bicarbonate, Blood gas analysis, Acidosis, Ketosis, Ketone bodies, Hyperglycemia

Core tip: Serial arterial blood gas measurements and intravenous sodium bicarbonate are often used to assess and correct acidosis associated with diabetic ketoacidosis. The available literature, primarily in patients with mild to moderately severe acidosis, does not support the routine use of sodium bicarbonate. Additionally, arterial sampling for blood gas measurement may not be necessary, nor does it appear to substantially add to the care of these patients. While neither intervention may be needed on a routine basis, there are special circumstances when either, or both, of these modalities is indicated and useful.