Great points! I practice very similarly. Thoughts on starting isotonic HCO3 when there is an AKI? BICAR ICU trial showed benefit with metabolic acidosis with concomitant aki. This study wasn’t a DKA trial, but I have been applying it to my patients with DKA. I’d love to get your opinion.
Great question...my thoughts are this: 1. Bicarb doesn’t replace the need to correct the cause of the underlying metabolic acidosis (It makes numbers look better and us feel better). Treat the cause, then consider bicarb. In DKA...Insulin, Insulin, Insulin, balanced crystalloids, and time 2. In patients with established, or new kidney injury, there was a clear signal toward benefit in row BICAR-ICU trial. But the BICAR-ICU trial used this thing called the AKIN score which requires knowing urine output for preceding 6 to 24 hours, which we don't have in the ED, but certainly do in the ICU 3. I believe the AKI in DKA to be due to volume depletion rather than intrinsic kidney injury and if that is the case, then volume >>>>>>>>>>>bicarb should fix this. My two cents Steve
bicar icu was very clear on who gets them benefits. a clear cut hagma who is ventilating at 40-60lpm has a low bicarb not because he's losing it, but because he's using it.
I would be very concerned about causing cerebral edema in kids with DKA...I personally would only consider using bicarbonate in kids if there is a peri-arrest/arrest situation
Fair point...but my bigger concern is the patient tiring out from the tachypnea...with HFNC you do get some better minute ventilation which compensates for the slower RR...at least that has been my experience
Bicarbonate therapy is a last ditch effort IMHO...it will be the rare time it is needed...most DKA will improve if appropriate amounts of insulin given + time...I use a ketoacidosis-driven strategy (i.e insulin titrated to anion gap) not a glucose driven strategy (i.e. insulin titrated to reduce glucose)...hope this helps
@SalimRezaie gotcha. I think that's what step 2 tested algorithm says to: crystaloids, insulin, +/- K, time, target anion gap, and then overlap SQ insulin by 1-2hrs when you reach that criteria. Thanks!
Whats your opinion regarding the administration of undiluted sodabicarbonate in severe metabolic acidosis with dka ? Or should we proceed with isotonic solution only ?
Hi What do we need to check befor bicarb infusion ph or hc03 in abg ? What if i have a case of dka with ph 7.1 and hco3 3.5 wat to do in these situations ?
What is the rate you are typically running your bicarb drip at? This is my preferred but can't ever say that my rate has any evidence behind it. I just pick a number based on prior discussion beith Crit care and nephrology.
That’s a great question… There is no high-level evidence to guide us on this… I generally start this trip at 100 cc an hour and titrate based on serial VBG/BMP
what I meant if for some reasons you need to intubate a DKA pt, is good to give IVP Bicar prior to intubation, also is recc'ed if they unfortunately needs ETT, to start bagging them ASAP after induction to avoid apnea, then after the ETT is placed to start RR 24-28 and VT 8 cc/kg and of course making sure the Pplat
No hard answer here...depends on the patient...some turn around quickly...others take longer...the key is to avoid them tiring out and requiring intubation
@@SalimRezaie I get that about DKA-in general-but those two numbers portend quite poorly. I am honestly not sure I have ever seen a patient with a pulse and a pH of 6.6. I would say at that point, Iacta alea est, because we have crossed the Rubicon. I think in a patient such as this it doesn’t make sense to quibble over BiCarb or not. Just give it because why not, what do you have to lose at this point.
Great points! I practice very similarly. Thoughts on starting isotonic HCO3 when there is an AKI? BICAR ICU trial showed benefit with metabolic acidosis with concomitant aki. This study wasn’t a DKA trial, but I have been applying it to my patients with DKA. I’d love to get your opinion.
Great question...my thoughts are this:
1. Bicarb doesn’t replace the need to correct the cause of the underlying metabolic acidosis (It makes numbers look better and us feel better). Treat the cause, then consider bicarb. In DKA...Insulin, Insulin, Insulin, balanced crystalloids, and time
2. In patients with established, or new kidney injury, there was a clear signal toward benefit in row BICAR-ICU trial. But the BICAR-ICU trial used this thing called the AKIN score which requires knowing urine output for preceding 6 to 24 hours, which we don't have in the ED, but certainly do in the ICU
3. I believe the AKI in DKA to be due to volume depletion rather than intrinsic kidney injury and if that is the case, then volume >>>>>>>>>>>bicarb should fix this.
My two cents Steve
bicar icu was very clear on who gets them benefits. a clear cut hagma who is ventilating at 40-60lpm has a low bicarb not because he's losing it, but because he's using it.
@@Admiration9 Yup...additionally only 41 patients with ketoacidosis in the study...majority were renal failure patients without DKA
Any thoughts on a pediatric patient presenting with the same labs in DKA ?
I would be very concerned about causing cerebral edema in kids with DKA...I personally would only consider using bicarbonate in kids if there is a peri-arrest/arrest situation
Question, with the HFNC, is there any concern with inducing a Haldane effect where CO2 offloading becomes even more inefficient?
Fair point...but my bigger concern is the patient tiring out from the tachypnea...with HFNC you do get some better minute ventilation which compensates for the slower RR...at least that has been my experience
So is your target more focused on getting the anion gap in range, and would you consider bicarbonate to that end?
Bicarbonate therapy is a last ditch effort IMHO...it will be the rare time it is needed...most DKA will improve if appropriate amounts of insulin given + time...I use a ketoacidosis-driven strategy (i.e insulin titrated to anion gap) not a glucose driven strategy (i.e. insulin titrated to reduce glucose)...hope this helps
@SalimRezaie gotcha. I think that's what step 2 tested algorithm says to: crystaloids, insulin, +/- K, time, target anion gap, and then overlap SQ insulin by 1-2hrs when you reach that criteria. Thanks!
Of course...and thanks for the question...good to clarify the details :)
What is the potential side effect If we give bicarb in the similar senario that you give?
The biggest issue is the potential to increase CO2 and make the patient more acidotic...
Whats your opinion regarding the administration of undiluted sodabicarbonate in severe metabolic acidosis with dka ? Or should we proceed with isotonic solution only ?
As a general rule I don't use sodium bicarbonate in over 95% of my DKA patients (Even the ones with pH
When you said 3 Amps of bicarbonate in a litre of water. Is it 8.4% or 4.2%?
In US we have 8.4%
@@SalimRezaie In UK its 4.2% vials. Should we use 6 vials in a litre?
@@amanhassan258 The math seems correct...however I don't use 4.2% so I would double check with your local poison control center
Hi
What do we need to check befor bicarb infusion ph or hc03 in abg ?
What if i have a case of dka with ph 7.1 and hco3 3.5 wat to do in these situations ?
What is the rate you are typically running your bicarb drip at? This is my preferred but can't ever say that my rate has any evidence behind it. I just pick a number based on prior discussion beith Crit care and nephrology.
That’s a great question… There is no high-level evidence to guide us on this… I generally start this trip at 100 cc an hour and titrate based on serial VBG/BMP
I would add, bicar prior to intubation.
Not sure intubation is a good idea in these patients...we won't be able to keep up with the minute ventilation to keep blowing of CO2...my two cents
what I meant if for some reasons you need to intubate a DKA pt, is good to give IVP Bicar prior to intubation, also is recc'ed if they unfortunately needs ETT, to start bagging them ASAP after induction to avoid apnea, then after the ETT is placed to start RR 24-28 and VT 8 cc/kg and of course making sure the Pplat
@@robertolarios7561 Can't remember the last time I had to intubate a DKA patient and we see lots of them here
HFNC for how long?
No hard answer here...depends on the patient...some turn around quickly...others take longer...the key is to avoid them tiring out and requiring intubation
Patient probability already has cerebral edema. I would give.
Maybe...hard to say
I feel like a patient with a pH of 6.6 and a K of 7.2 doesn’t need BiCarb, they need a coroner. But I get your point. 🫠
Ha...these patients typically get better with insulin, balanced crystalloids, and time...DKA is a reversible process
@@SalimRezaie I get that about DKA-in general-but those two numbers portend quite poorly. I am honestly not sure I have ever seen a patient with a pulse and a pH of 6.6. I would say at that point, Iacta alea est, because we have crossed the Rubicon. I think in a patient such as this it doesn’t make sense to quibble over BiCarb or not. Just give it because why not, what do you have to lose at this point.
@@greggae2735 Exactly the point of the video ;) TY for the discussion