The acidosis of DKA is initially compensated for by hyperventilation. Once the blood pH falls below 7-1, CNS depression can occur and this can prevent compensation. Acidosis will nearly always resolve with correction of fluid balance and cessation of ketosis following insulin therapy. Bicarbonate should be avoided unless the blood pH is less than 7-0, or less than 7-1 and not improving after the first few hours of fluid and insulin therapy. Many formulas exist relating the base excess to the child's weight and the bicarbonate requirement. However, because of the logarithmic relationship between [H+] and pH a dose of 2-5 ml/kg of 8-4% NaHCO3will correct the pH to 7-2 or 7-3 in all cases. This should be administered slowly over 2 hours by infusion. Recheck the pH after the first hour and stop the infusion if the pH is above 715 as the rest will correct naturally.
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