Table 3 Key studies on resolution of acidosis and ketosis with bicarbonate therapy in DKA

Hale et al. [13]

RCT

16 vs. 16

47 vs. 41

(1^st hr: 1 L isotonic saline for all)

Higher pH and bicarb levels at 2 hr

Br Med J 1984

(single center)

6.85 vs. 6.85

2^nd hr: 1 L isotonic bicarb vs.

1 L isotonic saline

in bicarb arm vs. control, p < 0.01

BUT

(3^rd hr: 1 L isotonic saline for all)

Slower decline in blood ketone in 1st hr in bicarb arm

Morris et al. [14]

RCT

10 vs.11

34 vs. 28

133.8 mmol if pH 6.9-6.99

no alkali

No difference in rate of change of pH, bicarb, ketones

Ann Intern Med 1986

(single center)

OR 89.2 mmol if pH 7.0-7.09

OR time to reach pH 7.3

7.03 vs. 7.00

OR 44.6 mmol if pH 7.1-7.14

OR bicarb levels to reach 15 mmol/L

(over 30 min, 2 hourly until pH ≥ 7.15)

Gamba et al. [15]

RCT

9 vs. 11

29 vs. 28

133.5 mmol/150 ml (pH 6.9-6.99)

0.9% saline, also

Higher pH at 2 hr in bicarb arm, p < 0.02

Rev Inves Clin 1991

double-blind

89 mmol/100 ml (pH 7.0-7.09)

in similar aliquots

AND higher bicarb in bicarb arm, p < 0.01

(single center)

7.05 vs. 7.04

44.8 mmol/50 ml (pH 7.1-7.14)

(over 30 min, repeated at 2 hr

Change in pH and bicarb larger in bicarb arm at 2 hr,

if pH increase by < 0.05)

p < 0.01

Okuda et al. [19]

Prospective

3 vs. 4

24 vs. 34

50 mmol/hr over 4 hr

No alkali

Paradoxical increase in plasma acetoacetate in 1^st 3 hr

J Clin Endocrinol Metab 1996

nonrandomized

in bicarb arm vs. control

nonblinded

6.98 vs. 7.27

(IV insulin 0.1 U/kg/hr + 0.9% saline)

Increase in plasma 3-hydroxybutyrate level after bicarb

(single center)

(p < 0.05)

ceased vs. steady decline throughout in control

Lutterman et al. [17]

Retrospective

12 vs. 12

41 vs. 34

167 mmol/L in 1 L

Low-dose insulin

No difference in mean pH rise in 1^st 2 hr

Diabetologia 1979

(single center)

over 1 hr (if pH ≤ 7.0)

IV 8 U/hr

OR mean time to reach pH ≥ 7.30

6.89

(with high dose insulin

OR rate of decline of ketosis

mean 260 U in 1st 6 hrs)

Lever et al. [18]

Retrospective

52 (73 cases)

22.5-37.4 vs.

mean 130-135 mmol

No alkali

No difference in mean change in bicarb level per hr

Am J Med 1983

(2 centers)

vs

24.5-48.0

(majority slow infusion)

OR mean change in pH per hr

21 (22 cases)

6.94-7.00 vs.

6.89-7.07

Viallon et al. [20]

Retrospective

24 vs. 15

45 vs. 47

mean 120 mmol (88-166)

No alkali

No difference in variation of mean pH, bicarb level, AG

Crit Care Med 1999

(single center)

1.4% over 1 hr infusion

anion gap in 1st 24 hr

6.93 vs. 7.00

OR mean time to reach pH > 7.30

OR urine ketone clearance

Green et al[24]

Retrospective

57 (90 cases)

9.6 vs. 10.1

mean 2.08 mmol/kg (0.53-

No alkali

Unadjusted rate of bicarb rise faster in bicarb arm at

Ann Emerg Med 1998

(single center)

vs

7.37 mmol/kg)

24 hr, p = 0.033

(pediatric)

49 (57 cases)

7.02 vs. 7.06

No difference in bicarb rise at 12 and 24 hr, or time to reach

bicarb of 20 mmol/L (matched pair and multivariate analysis)