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

Abstract

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.

Saline Compared to Balanced Crystalloid in Patients With Diabetic Ketoacidosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

“…The RCTs included DKA patients with variable severity of illness except one trial that excluded mild DKA (defined as blood glucose < 200 mg/dL = 11.1 mmol/L, serum bicarbonate above 15 or an anion gap < 16) ( 24 ). Most trials ( 24 – 26 , 30 , 31 ) excluded patients with end organ failure (defined as cerebral edema or low Glasgow Coma Score, renal failure requiring dialysis, respiratory failure requiring mechanical ventilation, myocardial infarction, or need of vasopressor or inotropic support).…”

“…There were a number of different balanced crystalloids examined, including PlasmaLyte ( 24 , 29 , 31 ), Ringer’s lactate ( 25 ), Ringerfundin ( 26 ), and Hartmann’s solution ( 30 ). One trial ( 27 ) used both Ringer’s lactate and PlasmaLyte due to a shortage in Ringer’s lactate that occurred during the study period.…”

“…The included RCTs randomized between 30 and 172 patients with DKA. Six of the RCTs were performed in adults (24–29), while two were performed in children (30, 31). One RCT was available only in abstract form (27); however, we were able to acquire more information through contact with study authors.…”

Intractable Normal Anion Gap Metabolic Acidosis in a Patient with Diabetic Ketoacidosis

“…This phenomenon is lost in severe cases or delayed presentations 5 . Secondly, during the treatment phase, NAGMA is aggravated by aggressive fluid resuscitation with normal saline 6 . Despite being widely used in fluid resuscitation, various studies have demonstrated that administration of large volumes of normal saline is associated with hyperchloraemia and hyperchloraemic metabolic acidosis.…”

A rare complication of hyperosmolar hyperglycaemic state in the intensive care unit

“…The arguments centre on the potential to exacerbate the narrow strong ion difference acidosis present in DKA through the introduction of large volumes of unbalanced crystalloid. [6][7][8] This discussion aside, continual electrolyte monitoring and replacement is required in both cases, because during the resuscitative phase, metabolic derangements may include hypokalaemia, hypophosphataemia, hypomagnesaemia, hypoglycaemia, and hyperchloraemia.…”