Copyright ©The Author(s) 2018.
World J Diabetes. Nov 15, 2018; 9(11): 199-205
Published online Nov 15, 2018. doi: 10.4239/wjd.v9.i11.199
Table 1 Clinical effects of metabolic acidosis[27,28]
SystemClinical effects
CardiovascularDepressed myocardium contractility
Changes in SVR
Acidosis-aided catecholamine release opposes acidosis-mediated vasodilation.
Net SVR depends on the sum of both effects
Conduction defects and dysrhythmias
Impaired response to exogenous vasopressors
PulmonaryIncreased work of breathing and respiratory failure
Compensatory alveolar hyperventilation
Dyspnea (Kussmaul’s breathing)
Acute decrease in hemoglobin oxygen affinity (Bohr Effect)
Temporary: Affinity rises after 36 h due to depletion of RBC 2,3-DPG
Hematological effectImpaired coagulation
Reduced fibrinogen and thrombin formation
Impaired clotting factor function
Factor Va
Factor VIIa
Factor VIIa/tissue factor complex
EndocrineInsulin resistance
Catecholamine, cortisol, PTH and aldosterone stimulation
Bone demineralization
Protein wasting
Free radical formation
Musculoskeletal systemAnti-anabolic effect on the bone growth centers in chronic metabolic acidosis
Muscle fatigue
Central nerve systemCerebral edema
Depressed sensorium
Immune systemImpaired leukocyte function
Increased susceptibility to infections
Table 2 Key findings and conclusions regarding the use of sodium bicarbonate in diabetic ketoacidosis
Sodium bicarbonate use in mild to moderate acidemia (pH ≥ 7.0) is associated with
No benefit in mortality or duration of hospitalization[12]
Possible transient benefit in reversal of acidosis[12,14,16]
Delay in resolution of ketosis[18]
Trend toward worsening of central nervous system acidosis[15]
Increased need for potassium supplementation[16]
Worsened tissue hypoxia[19]
Cerebral edema and prolonged hospitalization in pediatric patients[12]
Post-treatment metabolic alkalosis
Sodium bicarbonate use in severe acidemia (pH < 7.0) has not been well-studied
No improvement in morbidity or mortality in a small, randomized trial[15]
Routine use of sodium bicarbonate in diabetic ketoacidosis is not supported by the available literature
Several situations exist in which the use of sodium bicarbonate may be warranted
Severe acidosis
Life-threatening hyperkalemia
Recovery from saline-induced metabolic acidosis
Table 3 Key findings and conclusions regarding blood gas monitoring in diabetic ketoacidosis
Venous blood is similar to arterial sampling in measuring
Base excess[21]
Venous blood gas measurement may be used in place of arterial blood for the purposes of stratifying disease severity in diabetic ketoacidosis
Blood gas measurement does not often change management of diabetic ketoacidosis, especially when routine chemistries (including bicarbonate level) and ketone body identification are available[25]
Routine use of arterial and/or venous blood gas measurement may not be necessary in the evaluation and management of diabetic ketoacidosis
Exceptions where blood gas analysis would likely alter management include
Abnormal baseline serum bicarbonate levels
Chronic respiratory failure
Renal tubular acidosis
Acute respiratory compromise
Adequacy of respiratory compensation for metabolic acidosis
Respiratory muscle fatigue and failure