Conclusions

BCs reduce hyperchloremia and improve bicarbonate profiles compared with NS in patients with DKA, without increasing adverse events. However, the effect on clinically meaningful outcomes, particularly time to DKA resolution, duration of insulin infusion, and LOS, remains uncertain due to inconsistent findings and low-certainty evidence. Based on the GRADE assessment, the certainty of evidence is moderate for biochemical endpoints but low to very low for patient-important outcomes. While the biochemical advantages and consistent safety profile support considering BCs as an alternative to NS, the current evidence does not justify a definitive recommendation for BCs to become the standard of care. High-quality, adequately powered trials such as BEST-DKA are urgently needed to determine whether the biochemical benefits translate into improved clinical outcomes.