Metabolism/GlucosePlasma-Lyte 148 vs 0.9% saline for fluid resuscitation in diabetic ketoacidosis☆
Introduction
Patients with diabetic ketoacidosis (DKA) have hyperosmolar intracellular dehydration and osmotic diuresis, which result in severe volume contraction and body fluid deficit of 5% to 10% [1], [2]. Prompt volume resuscitation is vital to correct fluid losses, and restore circulating volume and tissue perfusion [3]. Rehydration alone, independent of insulin, has been demonstrated to improve the metabolic profile in terms of glycemic control and acid-base balance, and reduce insulin counter regulatory hormone levels [4]. In addition, these patients develop a high anion gap metabolic acidosis from accumulation of β-hydroxybutyrate and acetoacetate. This may change into a normal anion gap hyperchloremic metabolic acidosis with a persisting base deficit during treatment [5] due to both the administration of large volumes of saline for resuscitation and increased proximal tubular reabsorption of chloride as less bicarbonate becomes available [6].
Current guidelines recommend the use of crystalloids over colloids for volume resuscitation in patients with DKA, with the preferred use of 0.9% saline (NS), while acknowledging its potential biochemical disadvantages [7], [8]. The high chloride content in NS and the associated hyperchloremia could delay the resolution of acidosis during recovery [9], [10]. In that regard, balanced electrolyte solutions containing organic anions such as Plasma-Lyte 148 (PL) are physiologically more similar to body fluid composition, with a mild alkalization effect, and therefore might be beneficial for the reversal of acidemia. On the other hand, the use of these fluids that contain potassium might worsen hyperkalemia seen in the initial stages of DKA [11]. These concepts and theoretical concerns have not been thoroughly evaluated.
The objective of this study is to evaluate the biochemical and hemodynamic efficacy and safety, with the predominant use of PL compared with NS, in the initial volume resuscitation of patients with DKA. We hypothesized that the predominant use of PL would increase the rate of resolution of acidosis in DKA without inducing hyperkalemia.
Section snippets
Study design
We performed a multicenter retrospective study involving adult patients with DKA admitted to the intensive care units (ICUs) of 3 tertiary hospitals in Australia. This study was approved by all local Human Research Ethics Committees.
Study comparators
We compared the use of PL vs NS as the predominant crystalloid administered in the initial 12 hours of volume resuscitation. Plasma-Lyte 148 (Baxter Healthcare Corporation, Deerfield, IL) is a sterile, nonpyrogenic isotonic solution available for intravenous
Results
Fifty-five eligible patients with moderate to severe DKA admitted during the study period were identified. Of these, 23 patients fulfilled the inclusion and exclusion criteria and were included in the study. Table 1 summarizes the patients' baseline characteristics, which are comparable in both PL and NS groups, except for significantly higher baseline AppSID and SIG with a trend for lower baseline chloride levels in the NS group.
Nine patients were predominantly resuscitated with PL, and 14
Statement of key findings
We evaluated retrospectively the use of PL vs NS for fluid resuscitation in DKA. The results confirmed the hypothesis that PL would increase the rapidity and extent of resolution of acidosis in this setting. We found statistically significant early differences in changes of bicarbonate levels and SBE in favor of PL infusion, with the prevention of marked increase in chloride levels induced by NS, and no evidence of hyperkalemia with the use of PL. All these occurred with similar improvement in
Conflicts of interest
The authors have no conflicts of interest to declare.
Acknowledgments
Dr Horng-Ruey Chua was a recipient of the Singapore Health Manpower Development Programme award in 2010, which was co-funded by the Ministry of Health Singapore and National University Health System Singapore. The funds were used for his clinical and research training in Austin Health, Melbourne, Australia.
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Contributions: R.B., B.V., E.S., P.K., and H.R.C. conceived the study idea and proposal, and developed the study design. H.R.C., A.S., K.P., and S.L. collected the data. H.R.C. and R.B. performed the data analysis. H.R.C. and R.B. wrote the initial manuscript. All authors were involved in the revision of the manuscript, and take responsibility for the data and contents of the article.
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Co-Director, Australian and New Zealand Intensive Care Research Committee (ANZIC-RC), Monash University, School of Public Health and Preventive Medicine, 99 Commercial Road, Melbourne, Victoria 3004, Australia.