Reevaluating bicarbonate therapy in pediatric DKA: A propensity score-matched analysis of neurological and respiratory outcomes

Patel M, Afifi AM, Hercher RL, et al. Am J Emerg Med. 2025 Jul;97:45-50. PMID: 40683034.

Introduction

Bicarbonate therapy in pediatric diabetic ketoacidosis (DKA) remains controversial due to possible adverse outcomes, including neurological and respiratory complications.

Study Type: Retrospective cohort study with propensity score matching

Population: Pediatric DKA patients <12 years old (n=422 after matching)

Intervention: Bicarbonate therapy versus no bicarbonate

Outcomes: Cerebral edema, coma, pulmonary edema, acute respiratory failure

Key Findings

• No difference in cerebral edema incidence (RD=0.002; p=0.911)
• Significantly higher risk of coma (RD=0.047; p=0.001)
• Increased pulmonary edema risk (RD=0.048; p=0.001)
• Higher acute respiratory failure incidence (RD=0.071; p=0.008)

Context & Related Research

• Freeman et al., 2024: Bicarbonate used more in community EDs without increased complications compared to academic centers (PMID: 35993519), suggesting selective use may be safe.
• Yıldırımçakar et al., 2024: Using Ringer’s lactate improves acid-base status faster than saline, reducing DKA duration and risk of hyperchloremia (PMID: 36287591).
• Agarwal et al., 2025: Double-blind RCT favors Ringer’s lactate over saline as initial fluid, improving metabolic recovery (PMID: 36789972).
• Rugg-Gunn et al., 2021: UK guidelines recommend restricting bicarbonate to life-threatening acidosis with cardiac compromise (PMID: 34109360).
• Veverka et al., 2016: Two-bag IV fluid protocols reduce insulin therapy duration and effectively manage pediatric DKA without bicarbonate (PMID: 27801968).

Clinical Implications

• Avoid routine bicarbonate therapy in pediatric DKA due to increased risks of coma and respiratory complications.
• Consider balanced fluids like Ringer’s lactate to improve acid-base balance and reduce bicarbonate need.
• Reserve bicarbonate for severe acidosis with cardiac compromise, following guideline recommendations.

Strengths & Limitations

Future Directions

Prospective trials to clarify bicarbonate safety and optimized fluid management strategies in pediatric DKA are needed.

Despite no increased cerebral edema risk, bicarbonate therapy in pediatric DKA is linked to higher neurological and respiratory complications, warranting cautious use.

Listen to the Podcast

A short discussion of today’s highlight.

Open the episode in a new tab