Balanced crystalloids may be preferred for acute resolution of diabetic ketoacidosis

Diabetic ketoacidosis (DKA) may resolve more quickly after administration of balanced crystalloids compared with saline, according to a recent study.

Researchers performed a subgroup analysis of adults with DKA in two previously reported 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). Both were pragmatic, multiple-crossover, cluster randomized clinical trials done concurrently at a U.S. academic medical center between January 2016 and March 2017. They included adults in the ED and the ICU, respectively, with DKA, defined as a clinical DKA diagnosis, a plasma glucose level greater than 250 mg/dL (>13.9 mmol/L), a plasma bicarbonate level less than or equal to 18 mmol/L, and an anion gap greater than 10 mmol/L. The goal of the current study was to compare the clinical effects of balanced crystalloids and saline for acute DKA treatment, with a primary outcome of time between ED presentation and DKA resolution and a secondary outcome of time from initiation to discontinuation of continuous insulin infusion. The results were published Nov. 16 by JAMA Network Open.

One hundred seventy-two adults were included in the current study. Of these, 94 were assigned to receive balanced crystalloids and 78 were assigned to receive saline. By volume, 96% of the fluid received by the former group was lactated Ringer's solution. The median age was 29 years, and slightly more than half (52.3%) were women. The median volume of isotonic fluid administered in the ED and ICU was 4,478 mL (interquartile range [IQR], 3,000 to 6,372 mL). In a cumulative incidence analysis, time to DKA resolution was shorter in the balanced crystalloids group versus the saline group (median, 13.0 hours [IQR, 9.5 to 18.8 hours] vs. 16.9 hours [IQR, 11.9 to 34.5 hours], respectively), with an adjusted hazard ratio of 1.68 (95% CI, 1.18 to 2.38; P=0.004). The balanced crystalloids group also had a shorter time to discontinuation of insulin infusion (median, 9.8 hours [IQR, 5.1 to 17.0 hours] vs. 13.4 hours [IQR, 11.0 to 17.9 hours]), with an adjusted hazard ratio of 1.45 (95% CI, 1.03 to 2.03; P=0.03). Hypokalemia was less common in the balanced crystalloids group than in the saline group (adjusted odds ratio, 0.35 [95% CI, 0.13 to 0.91]), while other clinical outcomes between the groups were similar.

The authors noted that the intervention was not blinded, that study participants were initially identified by ICD-10-CM code, and that the data were from one academic medical center, among other limitations. They concluded that in this analysis of ED and ICU patients, balanced crystalloids resulted in faster DKA resolution. “According to the median values, balanced crystalloids were associated with an absolute reduction of about 4 hours and a relative reduction of approximately 20% to 30% in the time to DKA resolution and discontinuation of insulin infusion,” the authors wrote. “There was no subgroup or outcome in which saline appeared superior to balanced crystalloids. These results suggest that balanced crystalloids may be preferred over saline for the acute management of adults with DKA.”