In this episode, I’ll discuss whether balanced crystalloid therapy could lead to faster resolution of DKA than normal saline.
Fluid resuscitation with normal saline is known to cause more hyperchloremic metabolic acidosis when compared to balanced crystalloid fluids such as lactated ringers. It is physiologically plausible that this difference between fluids could lead to a difference in time to resolution of diabetic ketoacidosis.
Researchers from Vanderbilt University Medical Center published a post-hoc subgroup analysis of 2 previously reported companion trials—Saline Against Lactated Ringer’s or Plasma-Lyte in the Emergency Department (SALT-ED) and the Isotonic Solutions and Major Adverse Renal Events Trial (SMART) to examine the difference between the two fluids when treating patients with DKA.
This study included adults who presented to the ED with a clinical diagnosis of DKA.
The primary outcome was the time between ED presentation and DKA resolution and the secondary outcome was the time between initiation and discontinuation of continuous insulin infusion.
The authors found 94 patients with DKA in the balanced crystalloids group and 78 in the saline group.
Cumulative incidence analysis revealed a 3.9 hour shorter time to DKA resolution in the balanced crystalloids group at 13 vs 16.9 hours (adjusted hazard ratio = 1.68; 95% CI, 1.18-2.38; P = .004). Cumulative incidence analysis also revealed a 3.6 hour shorter time to insulin infusion discontinuation in the balanced crystalloids group at 9.8 vs 13.4 hours (adjusted hazard ratio = 1.45; 95% CI, 1.03-2.03; P = .03).
The authors “believe that the results of this study add to the accumulating evidence suggesting balanced crystalloids are better resuscitation fluids than saline for many patients and may have particular benefits for patients with DKA.”
Given that posthoc subgroup analysis like this one is considered hypothesis-generating, I would not expect the DKA guidelines to change from this study alone, however, clinicians may choose more frequently to use balanced crystalloids to treat patients with DKA
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