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Bicarbonate therapy in children with DKA

Three Part Question

In a [child with DKA], what [degree of acidosis] is necessary to [commence bicarbonate therapy]?

Clinical Scenario

A 14 year old male is under your care and being treated for diabetic ketoacidosis. Fluid resuscitation occurred and insulin was commenced. However, his blood gases continue to reveal a severe degree of acidaemia (pH<6.9). You wonder whether this patient will benefit from bicarbonate therapy and if there is any evidence to prove its efficacy.

Search Strategy

Medline (1950-07/09) using the OVID interface, Cochrane (2009) and Embase (2009) [exp.Bicarbonates] AND [exp.Diabetic ketoacidosis]. LIMIT to human AND children aged 0-18 AND English language.

Search Outcome

128 papers were found in total and 2 were selected as suitable.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Churku Mohan Reddy and Eduardo Orti
Nineteen patients, nine males and ten females with 24 episodes of diabetic ketoacidosisCase studyKetoacidosis was corrected with 2.5mEq of sodium bicarbonate/kg of body weight.-Small sample size


Biicarbonate therapy does not affect oxygen transport in juvenile diabetic ketoacidosis. However, very low pH has adverse effects on the respiratory center1 and on myocardial contractility.

Clinical Bottom Line

Bicarbonate therapy is only indicated in the managemenet of diabetic ketoacidosis in children with severe acidosis(pH<6.9)and after discussion with senior.


  1. Viallon, Alain MD; Insulin and Sodium Bicarbonate Treatment of Diabetic Ketoacidosis in Children J Natl Med Assoc 1977 May; 69(5): 355–357.