2025 Southeastern Residency Conference

Title: EFFICACY OF BALANCED SOLUTIONS VERSUS NORMAL SALINE ON DIABETIC KETOACIDOSIS RESOLUTION
Authors: Benny Zhang, PharmD, Bibidh Subedi, PharmD, BCCCP, Otsanya Ochogbu, PharmD


Background: Diabetic keto-acidosis (DKA) is a serious life-threatening complication. The initial management involves fluid resuscitation with crystalloids to restore intravascular volume. Current guidelines recommend normal saline (NS), however emerging evidence suggest that balanced crystalloids, such as Lactated Ringer’s (LR), may be a more appropriate choice of fluid in the acute management of DKA given the risk of hyperchloremic non-anion gap metabolic acidosis and acute kidney injury with NS. The purpose of this study is to compare the efficacy of LR versus NS in the management of DKA.


Methods: This is a multi-site, retrospective, observational study at a 3,260-bed community teaching hospital system comparing LR to NS in patients admitted with DKA. Patients will be identified via the electronic medical record and included if age 18 or greater, admitted between August 1st, 2022 to August, 31st, 2024 with a confirmed diagnosis of DKA (using ICD-9/10 codes or according to the ADA guideline criteria, defined as: blood glucose >200 mg/dL or prior history of diabetes, β-Hydroxybutyrate concentration ≥3 mmol/L, and pH <7.3 and/or bicarbonate <18 mEq/L), that received continuous infusions of either LR or NS. Patients were excluded if they were transferred from an outside hospital and had end-stage renal disease. The primary outcome was time to DKA resolution (defined as: (1) blood glucose <200 mg/dL and two of the following (2) bicarbonate ≥ 18 mEq/L, venous pH ≥ 7.3, and a calculated anion gap ≤ 12 mEq/L). Secondary outcomes include incidence of hyperchloremic non-anion gap metabolic acidosis, incidence of hypokalemia, time to discontinuation of maintenance fluid, acute kidney injury, ICU length of stay, and hospital length of stay.


Results: A total of 1738 patients were screened for inclusion: 274 patients in the LR group and 1464 patients in the NS group. 152 patients were included in the study, with 76 patients in each group. The baseline median anion gap (33 mmol/L vs 23 mmol/L; p<0.001) and β-Hydroxybutyrate (8.6 mmol/L vs 4.8 mmol/L; p<0.001) was higher in the LR group compared to the NS group, respectively. Additionally, the baseline median pH (7.13 vs 7.24; p<0.001) and bicarbonate (9 mmol/L vs 15 mmol/L; p<0.001) was lower in the LR group compared to the NS group, respectively. There was no difference in comorbidities between groups and the most common cause for DKA was non-compliance (49%). More patients in the LR group were classified as severe DKA when compared to the NS group; 59% vs 24%, p<0.001. The total amount of intravenous fluid received was greater in the NS group compared to the LR group: 5842 mL vs 4575 mL, p=0.006. Lactated Ringer’s was associated with faster time to DKA resolution and time to anion gap closure when compared to NS; 20.5 hr vs 24.1 hr (p=0.022) and 16.4 hr vs 20.3 hr (p=0.004), respectively. There was no difference in the incidence of hyperchloremic non-anion gap metabolic acidosis, hypokalemia, time to discontinuation of maintenance fluid, acute kidney injury, and hospital length of stay. ICU length of stay was longer in the LR group (51 hours) compared to the NS group (38 hours), p=0.015.


Conclusion: The use of LR in patients with DKA was associated with a faster time to DKA resolution and anion gap closure compared with NS, with no difference in adverse events between both groups. The findings of this study suggest that balanced crystalloids may be a more appropriate choice of fluid therapy in the management of DKA, but larger prospective studies are warranted to validate the findings of this study.