I have a craaaaazy question about sodium bicarbonate in DKA patients. I totally understand that the evidence doesn't support pushing bicarb on them to correct their acidosis.....but what about a patient who is tiring out and is about to be intubated? If they are breathing hard and their pH is ALREADY low (let's say 6.8), isn't there a risk of them transiently becoming MORE acidotic during the peri-intubation period where you sedate and paralyze them? In this case, would it make sense to push an ampule of bicarbonate WHILE you intubating them? Once they are intubated, then you can help the patient blow off that extra CO2 from the bicarbonate...is this a good idea or a stupid one? Please advise. Big hugs.
pH will not get better in this instance. Bicarb converts metabolic acidosis to the PaCO2 during the intubation and the pH is not improved. In some circumstances the pH gets worse. See Acid Base 5 on emcrit site for all of the references.
Great explanation of the acid/base physiology in DKA. Any thoughts on which fluid is best to give in severe DKA with pH <7 during the initial resus while waiting for insulin to work? I feel like large volumes of NS could worsen pH by causing a hyperchloremic acidosis. 1/2 NS - too much free water? Plasmalyte?
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Whit F. - January 18, 2015 7:55 PM
I have a craaaaazy question about sodium bicarbonate in DKA patients. I totally understand that the evidence doesn't support pushing bicarb on them to correct their acidosis.....but what about a patient who is tiring out and is about to be intubated? If they are breathing hard and their pH is ALREADY low (let's say 6.8), isn't there a risk of them transiently becoming MORE acidotic during the peri-intubation period where you sedate and paralyze them? In this case, would it make sense to push an ampule of bicarbonate WHILE you intubating them? Once they are intubated, then you can help the patient blow off that extra CO2 from the bicarbonate...is this a good idea or a stupid one? Please advise. Big hugs.
EMCrit - January 19, 2015 6:34 PM
pH will not get better in this instance. Bicarb converts metabolic acidosis to the PaCO2 during the intubation and the pH is not improved. In some circumstances the pH gets worse. See Acid Base 5 on emcrit site for all of the references.
s
Matthew T. - January 20, 2015 5:38 PM
Great explanation of the acid/base physiology in DKA. Any thoughts on which fluid is best to give in severe DKA with pH <7 during the initial resus while waiting for insulin to work? I feel like large volumes of NS could worsen pH by causing a hyperchloremic acidosis. 1/2 NS - too much free water? Plasmalyte?