Balanced electrolyte solutions versus isotonic saline in adult patients with diabetic ketoacidosis: A systematic review and meta-analysis

Catahay, Jesus Alfonso; Polintan, Edgar Theodore; Casimiro, Michael; Notarte, Kin Israel; Velasco, Jacqueline Veronica; Ver, Abbygail Therese; Pastrana, Adriel; Macaranas, Imee; Patarroyo‐Aponte, Gabriel; Lo, Kevin Bryan

doi:10.1016/j.hrtlng.2022.03.014

Cited by 17 publications

(22 citation statements)

References 22 publications

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“…Our results are consistent with prior literature suggesting balanced crystalloids may be preferred over NS in the acute management of patients presenting with DKA. [5][6][7][8][9][10][11] Previous studies comparing balanced crystalloids to NS for the treatment of DKA have demonstrated no significant difference between groups with regards to resolution of acidosis; however, these studies were limited by sample size and were powered to detect differences in only one variable of DKA resolution, introducing risk for type II error. 14,15 In a healthcare era focused on decreasing hospitalization-associated resource utilization, cost, and LOS, our results are particularly relevant as they demonstrate a significantly significant decreased ICU LOS, decreased volume of fluid administered, decreased potassium supplementation, and a trend toward decreased hospital LOS.…”

Section: Discussionmentioning

confidence: 99%

“…1,3 However, this approach increases the risk of hyperchloremic metabolic acidosis (HMA) and there is growing evidence of additional detrimental metabolic sequelae that occur with the use of NS in the management of DKA. [5][6][7][8][9][10][11] Development of iatrogenic HMA in the setting of DKA management may delay resolution of acidosis, delay transfer to lower level of hospital care, and increase length of stay (LOS). 6,[8][9][10] Utilization of balanced crystalloids for fluid resuscitation in the setting of other indications, such as sepsis, has demonstrated reduced adverse renal events in critically ill and noncritically ill patients, as well as decreased all-cause mortality rate in critically ill patients.…”

Section: Introductionmentioning

confidence: 99%

“…[5][6][7][8][9][10][11] Development of iatrogenic HMA in the setting of DKA management may delay resolution of acidosis, delay transfer to lower level of hospital care, and increase length of stay (LOS). 6,[8][9][10] Utilization of balanced crystalloids for fluid resuscitation in the setting of other indications, such as sepsis, has demonstrated reduced adverse renal events in critically ill and noncritically ill patients, as well as decreased all-cause mortality rate in critically ill patients. 12,13 A recent secondary analysis of two cluster randomized controlled trials demonstrated that balanced crystalloids, compared with NS, resulted in more rapid DKA resolution.…”

Section: Introductionmentioning

confidence: 99%

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Evaluation of a Protocol Change Promoting Lactated Ringers Over Normal Saline in the Treatment of Diabetic Ketoacidosis

Johnson,

Drincic,

Buddenhagen

et al. 2024

J Diabetes Sci Technol

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Background: Current guidelines recommend normal saline (NS) for fluid resuscitation in the management of patients presenting with diabetic ketoacidosis (DKA). However, previous prospective studies have demonstrated improvement in patient-specific outcomes, including time to DKA resolution, when balanced crystalloid fluids are used. Methods: We conducted a single institution, retrospective cohort study of adult patients admitted with DKA before and after a protocol change within our institution, which shifted the default resuscitative and maintenance fluid in our DKA management protocol from NS to lactated Ringer’s solution (LR). The primary outcome was time from DKA clinical presentation until DKA resolution. The secondary outcome was time to discontinuation of DKA protocol insulin drip. Results: Of 246 patients meeting inclusion criteria, 119 were in the NS group (preprotocol change, where NS was the default resuscitative fluid) and 127 to the LR group (postprotocol change, where LR was the default resuscitative fluid). Time to DKA resolution was significantly decreased in the LR group (mean = 17.1 hours; standard deviation [ SD] = 11.0) relative to the NS group (mean = 20.6 hours; SD = 12.2; P = .02). Duration of DKA protocol insulin drip was shorter in the LR group (mean = 16.0 hours; SD = 8.7) compared with the NS group (mean = 21.4 hours; SD = 12.5; P < .001). Conclusions: In this retrospective cohort study, protocolized DKA intravenous fluid management with LR resulted in shorter time to resolution of DKA and reduced duration of DKA protocol insulin drip.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Evaluation of a Protocol Change Promoting Lactated Ringers Over Normal Saline in the Treatment of Diabetic Ketoacidosis

Johnson,

Drincic,

Buddenhagen

et al. 2024

J Diabetes Sci Technol

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“…This meta-analysis represents the current, most up-to-date evidence on balanced crystalloid solutions versus saline in patients with DKA (Table 1). This was followed by publication of several, very similar systematic reviews which included the same trials and provided similar conclusions [16,17].…”

Section: Recent Evidencementioning

confidence: 90%

Fluid therapy in diabetic ketoacidosis

Ramanan,

Delaney,

Venkatesh

2023

Current Opinion in Clinical Nutrition &Amp; Metabolic Care

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Purpose of review To evaluate recent evidence (2021–2023) on fluid therapy in diabetic ketoacidosis. Key evidence gaps which require generation of new evidence are discussed. Recent findings Balanced crystalloid solutions, compared to the commonly recommended and used 0.9% sodium chloride solution (saline), may result in better outcomes for patients with diabetic ketoacidosis, including faster resolution of acidosis, less hyperchloremia and shorter hospital length of stay. Upcoming results from randomized trials may provide definitive evidence on the use of balanced crystalloid solutions in diabetic ketoacidosis. Evidence remains scarce or conflicting for the use of “two-bag” compared to conventional “one-bag” fluid, and rates of fluid administration, especially for adult patients. In children, concerns about cerebral oedema from faster fluid administration rates have not been demonstrated in cohort studies nor randomized trials. Summary Fluid therapy is a key aspect of diabetic ketoacidosis management, with important evidence gaps persisting for several aspects of management despite recent evidence.

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“…3) zu sein. Es liegen auch Studien vor, die auf einen günstigeren klinischen Verlauf der diabetischen Ketoazidose bei Therapie mit einer kristalloiden Lösung mit einer dem Blutplasma ähnlicheren Elektrolyt-Zusammensetzung im Vergleich zu einer Therapie mit einer 0,9 % Kochsalzlösung hinweisen [14][15][16][17]. In der Regel sollte bei schweren Stoffwechselentgleisungen in der ersten halben Stunde bis Stunde 1 l Flüssigkeit verabreicht werden und auch in den weiteren 1 ½ bis 2 h jeweils etwa 1 l pro Stunde in Abhängigkeit von Hydratation, Diurese, Körpergewicht, kardialer und renaler Funktion sowie Elektrolyten.…”

Section: Leitlinien Für Die Praxisunclassified

Therapie der akuten diabetischen Stoffwechselentgleisungen bei Erwachsenen (Update 2023)

Kaser

Sourij

Clodi

et al. 2023

Wien Klin Wochenschr

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ZusammenfassungAkute Stoffwechselentgleisungen können für Erwachsene in Abhängigkeit von ihrem Ausmaß lebensbedrohlich sein. Dementsprechend sind eine rasche umfassende Diagnostik und Therapie sowie eine enge Überwachung der Vitalparameter und Laborbefunde erforderlich. Bei der Therapie, die sich bei der ketoazidotischen (DKA) und hyperglykämisch-hyperosmolaren (HHS) Form nicht wesentlich unterscheidet, kommt dem Ausgleich des meist beträchtlichen Flüssigkeitsdefizits mit mehreren Litern einer physiologischen kristalloiden Lösung eine vorrangige Rolle zu. Bei den Elektrolyten ist insbesondere auf eine ausgeglichene Serum-Kalium-Konzentration zu achten. Normal-Insulin oder rasch wirksame Analoga können initial als i.v.-Bolus verabreicht werden, in der Folge jedoch kontinuierlich über einen Perfusor. Die Umstellung auf eine subkutane Insulintherapie soll erst bei ausgeglichenem Säure-Basen-Haushalt und zufriedenstellender Glykämie erfolgen.

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Balanced electrolyte solutions versus isotonic saline in adult patients with diabetic ketoacidosis: A systematic review and meta-analysis

Cited by 17 publications

References 22 publications

Evaluation of a Protocol Change Promoting Lactated Ringers Over Normal Saline in the Treatment of Diabetic Ketoacidosis

Evaluation of a Protocol Change Promoting Lactated Ringers Over Normal Saline in the Treatment of Diabetic Ketoacidosis

Fluid therapy in diabetic ketoacidosis

Therapie der akuten diabetischen Stoffwechselentgleisungen bei Erwachsenen (Update 2023)

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