Author: Gretchen Hinson, M.D. Educational Pearls: Controversial topic. Pathophysiology - acidosis leads to an extracellular potassium shift. Patients in DKA will be intracellularly potassium deplete, but will have a falsely normal/elevated serum potassium. 3 risk of giving bicarb in DKA - alkalosis will drive potassium intracellularly but can overshoot (hypokalemia) and  increase risk of arrhythmias; bicarb slows clearance of ketones and will transiently increase their precursors; bicarb can cause elevated CSF acidosis. 3 instances when appropriate to give bicarb in DKA: DKA in arrest; hyperkalemic in DKA with arrhythmia; fluid and vasopressor refractory hypotension. References: Bratton, S. L., & Krane, E. J. (1992). Diabetic Ketoacidosis: Pathophysiology, Management and Complications. Journal of Intensive Care Medicine, 7(4), 199-211. doi:10.1177/088506669200700407 Chua, H., Schneider, A., & Bellomo, R. (2011). Bicarbonate in diabetic ketoacidosis - a systematic review. Annals of Intensive Care, 1(1), 23. doi:10.1186/2110-5820-1-23