Under what condition is bicarbonate therapy indicated in DKA?

• A. In all DKA cases.
• B. Only if blood glucose > 600 mg/dL.
• C. Never.
• D. In DKA with pH less than 6.9; otherwise bicarbonate is not routinely used.

Answer: (D)

The main idea is that bicarbonate is not routinely used in DKA; it’s reserved for the most severe acidemia. In DKA, fluids and insulin address the underlying problems—dehydration, hyperglycemia, and ketosis—so the acidosis typically improves as ketosis resolves. Bicarbonate can help only when the acidemia is profound, because very low pH (below about 6.9) carries a high risk of hemodynamic instability and worsened outcomes if not corrected. In such severe cases, giving bicarbonate can temporarily raise pH and support circulation, but it must be used carefully due to potential downsides—shifting potassium extracellularly and other electrolyte disturbances, possible cerebral effects, and interference with the ongoing correction process. When the acidosis is not as severe (pH above 6.9), bicarbonate does not improve outcomes and is not routinely indicated, since the body will correct the acidosis with fluids and insulin.