Resuscitation with balanced electrolyte solution prevents hyperchloremic metabolic acidosis in patients with diabetic ketoacidosis

Mahler, Simon A.; Conrad, Steven A.; Wang, Hao; Arnold, Thomas C.

doi:10.1016/j.ajem.2010.02.004

Cited by 139 publications

(109 citation statements)

References 17 publications

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“…These findings are similar to the study done by Chua et al (2012) and Mahler et al (2011). Plasmalyte was used as the balanced fluid which caused less hyperchloremic acidosis compared to normal saline.…”

Section: Discussionsupporting

confidence: 80%

Comparing Sterofundin to 0.9% Sodium Chloride Infusion in Managing Diabetic Ketoacidosis: A Pilot Study

Muhamad¹

2017

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ABSTRAK Penggantian cecair adalah rawatan utama untuk kencing manis ketoacidosis (DKA). Pada masa ini pilihan terbaik daripada cecair masih diperdebatkan. 0.9% Normal Saline (NS) yang menyebabkan ketidakseimbangan metabolik dan asidosis metabolik biasanya digunakan. Sterofundin® merupakan kristaloid & Health Dec 2017;12(2): 179-192 Rossman H. et al. (Malaysian Clinical Practice Guidelines 2015). The ideal fluid for managing diabetic ketoacidosis (DKA) is controversial. Following substantial fluid loss due to osmotic diuresis, fluid deficit can be estimated up to 100 ml/ kg which is corrected within 24 hrs. Crystalloid 0.9% normal saline (NS) is currently the mainstay therapy for fluid replacement. Fluid replacement regiment for a systolic BP > 90 mmHg is 1000 mL of NS for the 1 st hr, another 1000 mL of NS for next 2 hrs and 1000 Kata kunci: jurang anion, diabetic ketoacidoses, keton, ph , saline, sterofundin ABSTRACTFluid replacement is the mainstay treatment for diabetic ketoacidosis (DKA). Currently, the best choice of fluids is still debatable. An amount of 0.9% sodium chloride is commonly used. Sterofundin® is an alternative crystalloid that is assumed to expedite resolution of acidosis. Advantages in sterofundin content being smaller significant ion difference (SID) to plasma and lower chloride content. The main objective of the study was to compare rate of acidosis resolution in DKA patients between treatment with 0.9% normal saline and Sterofundin over 12 hrs. Other objectives were to compare significant ion difference (SID), 12-hr blood ketone clearance and electrolyte balance between the two groups. The study was a prospective open labelled randomized control trial. This study was conducted over 6 months. Sample size of 18 was obtained with 9 for each arm. Main difference between two groups was initial median 2-hr pH level improvement (NS = +0.006 vs. Sterofundin = +0.05, P=0.063), however not being significant. Ketone, anion gap reduction, bicarbonate normalisation, sodium, chloride, urea and creatinine levels failed to show any significant differences between both groups. Twelve-hour median chloride levels increments were higher in the NS group (+11) compared to the sterofundin group (+6). There was no difference between mortality and morbidity. Comparing the two fluid groups, there was no significant biochemical differences during treatment of DKA. This was a pilot study that can initiate further clinical trials.

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Section: Discussionsupporting

confidence: 80%

Comparing Sterofundin to 0.9% Sodium Chloride Infusion in Managing Diabetic Ketoacidosis: A Pilot Study

Muhamad¹

2017

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“…Even if it is often considered self-limiting and benign in nature, 0.9% NaClinduced metabolic acidosis will be added to any other possible causes of acidosis, especially in critically ill patients, thereby potentially complicating or worsening the clinical picture (as during the treatment of diabetic ketoacidosis, as an example) [27,28]. Moreover, the induction of hyperchloremic metabolic acidosis in relation to 0.9% NaCl may also mislead clinicians into looking for, and maybe erroneously treating, a "classic" cause of metabolic acidosis in an otherwise healthy patient [29].…”

Section: The Importance Of Chloride Content and Its Pathophysiologic mentioning

confidence: 99%

Intravenous balanced solutions: from physiology to clinical evidence

Länger

Santini

Scotti

et al. 2015

Anaesthesiol Intensive Ther

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Abstract"Balanced" solutions are commonly defined as intravenous fluids having an electrolyte composition close to that of plasma. As such, they should minimally affect acid-base equilibrium, as compared to the commonly reported 0.9% NaCl-related hyperchloremic metabolic acidosis. Recently, the term "balanced" solution has been also employed to indicate intravenous fluids with low chloride content, being the concentration of this electrolyte the most altered in 0.9% NaCl as compared to plasma, and based upon a suggested detrimental alteration of renal function associated with hyperchloremia. Despite efforts made towards its identification, the ideal balanced solution, with minimal effects on acid-base status, low chloride content, and adequate tonicity, is not yet available. After the accumulation of pre-clinical and clinical physiologic data, in the last three years, several clinical trials, mostly observational and retrospective, have addressed the question of whether the use of balanced solutions has beneficial effects as compared to the standard of care, sometimes even suggesting an improvement in survival. Nonetheless, the first large randomized controlled trial comparing the effects of a balanced vs. unbalanced solutions on renal function in critically-ill patients (SPLIT trial, the 0.9% saline vs. Plasma-Lyte 148 for Intensive Care Unit Fluid Therapy), just recently published, showed identical equipoise between the two treatments. In the present review, we offer a comprehensive and updated summary on this issue, firstly, by providing a full physiological background of balanced solutions; secondly, by summarizing their potential pathophysiologic effects; and lastly, by presenting the clinical evidence available to support their use at the present time.

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“…This occurred due to similar characteristics between two types of solution, which were isotonic to plasma and similar total volume given to the subjects. 4,8 The distribution of lactate level was varied although there was no significant difference between both groups. This might be attributable to the two types of solution; normal saline and BES, did not contain any lactate.…”

Section: Discussionmentioning

confidence: 99%

“…The balanced electrolyte solution (BES) is known to have electrolyte contents similar to physiological condition, and is suggested to be used during management of diabetic ketoacidosis patients. Mahler et al 4 mentioned that patients with diabetic ketoacidosis receiving normal saline solution had higher chloride concentration in comparison with patients receiving BES. Van Zyl et al 5 presented the normalization of pH was non-significantly faster in DKA patients resuscitated with ringer's lactate instead of normal saline.…”

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confidence: 99%

The effect of balanced electrolyte solution versus normal saline in the prevention of hyperchloremic metabolic acidosis in diabetic ketoacidosis patients: a randomized controlled trial

2017

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The effect of balanced electrolyte solution versus normal saline in the prevention of hyperchloremic metabolic acidosis in diabetic ketoacidosis patients: a randomized controlled trial Keywords: balanced electrolyte solution, diabetic ketoacidosis, hyperchloremic acidosis, normal saline, standard base excess, strong ion difference (-4,88±5,69 vs -9,68±5,64; p=0,009), 24 jam (-3,99±4,27 vs -8,7± 5,35; p=0,023), dan 48 jam (-4,06±4,11 vs -7,01±5,46; p=0,009) . Selisih nilai BES dan SID tiap pengukuran dengan nilai awal jam 0 (delta BES dan delta SID) lebih tinggi pada kelompok BES, tetapi tidak signifikan. Kesimpulan: Penelitian ini menunjukkan bahwa balanced electrolyte solution (BES) sebagai cairan alternatif untuk resusitasi pasien KAD dapat mengurangi efek asidosis hiperkloremik dengan rerata aktual dan delta SID dan SBEyang lebih tinggi, tetapi tidak secara signifikan lebih superior dibandingkan dengan normal saline. ABSTRACTBackground: In resuscitation, normal saline could cause hyperchloremic metabolic acidosis, while balanced electrolyte solution is a crystalloid fluid resembling blood plasma with lower chloride content. This study compared the effect of normal saline and balanced electrolyte solution Ringerfundin (BES) as the resuscitation fluid in diabetic ketoacidosis (DKA) patients. Parameters applied in this study were standard base excess (SBE) as resuscitation's result indicator and strong ion difference (SID) to measure chloride's influence in developing hyperchloremic acidosis. Methods:A prospective, randomized, single blind controlled trial was conducted at the Emergency Department of Cipto Mangunkusumo Hospital. Thirty subjects with blood sugar >250 mg/dl, arterial pH <7.35 mg/dl, and positive blood ketone were randomly allocated to receive either normal saline (NS) or RingerfundinÒ (BES) as the standardized resuscitation protocol. Data analysis was performed using the unpaired T-test and the Mann Whitney test to compare the SBE and the SID means between both groups. Additional parameters were the level of consciousness, blood sugar level, vital signs, blood gas analysis, lactate, electrolyte, and blood ketone. Results:The mean SID in the BES group was significantly greater than the NS group of all measurements (p<0.05). The BES group had significantly higher mean SBE compared to the NS group at 18 hours (-4.88±5.69 vs -9.68±5.64; p=0.009), 24 hours (-3.99±4.27 vs -8.7±5.35; p=0.023), and 48 hours (-4.06±4.11 vs -7.01±5.46; p=0.009). BES resulted in nonsignificant higher delta SBE and SID than NS. Additional parameters were not different between both groups. Conclusion:This study showed that fluid resuscitation of DKA patients with BES resulted in slightly but not significantly higher mean actual SBE and SID than NS. suggesting that BES as an alternative fluid resuscitation to prevent hyperchloremic acidosis in diabetic ketoacidosis patients was not superior to NS.

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Resuscitation with balanced electrolyte solution prevents hyperchloremic metabolic acidosis in patients with diabetic ketoacidosis

Cited by 139 publications

References 17 publications

Comparing Sterofundin to 0.9% Sodium Chloride Infusion in Managing Diabetic Ketoacidosis: A Pilot Study

Comparing Sterofundin to 0.9% Sodium Chloride Infusion in Managing Diabetic Ketoacidosis: A Pilot Study

Intravenous balanced solutions: from physiology to clinical evidence

The effect of balanced electrolyte solution versus normal saline in the prevention of hyperchloremic metabolic acidosis in diabetic ketoacidosis patients: a randomized controlled trial

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