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

Dita Aditianingsih, Anne S. Djaja, Yohanes W.H. George



Background: 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 non-significant 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.


balanced electrolyte solution; diabetic ketoacidosis; hyperchloremic acidosis; normal saline standard base excess; strong ion difference;

Full Text:



  1. Kitabchi AE, Umpirezz GE, Miles JM, Fisher JN. Hyperglycemic crisis in adult patients with diabetes. Diabetes Care. 2009;32(7):1335–43.
  2. [Internet]. Joint british diabetes societies inpatient care group. The management of diabetic ketoacidosis in adult [update: 2013 Sep; cited 2014 Nov]. Available from:
  3. Scheingraber S, Rehm M, Sehmisch C, Finsterer U. Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologyc surgery. Anesthesiology. 1999;90(5):1265–70.
  4. Mahler SA, Conrad SA, Wang H, Arnold TC. Resuscitation with balanced electrolyte solution prevents hyperchloremic metabolic acidosis in patient with diabetic ketoacidosis. Am J Emerg Med. 2011;29(6):670–4.
  5. Van Zyl DG, Rheeder P, Delport E. Fluid management in diabetic-acidosis--Ringer's lactate versus normal saline: A randomized controlled trial. QJM. 2012;105(4):337–43.
  6. Park M, Noritomi DT, Maciel AT, de Azevedo LC, Pizzo VR, da Cruz-Neto LM. Partitioning evolutive standard base excess determinants in septic shock patients. Rev Bras Ter Intensiva. 2007;19(4):437–43s.
  7. Stewart PA. Modern quantitative acid-base chemistry. Can J Physiol Pharmacol. 1983;61(12):1444–61.
  8. Bellomo R, Naka T, Baldwin I. Intravenous fluids and acid base balance. Contrib Nephrol. 2004;144:105–18.
  9. Badr A, Nightingale P. An alternative approach to acid base abnormalities in critically ill patients. Contin Educ Anaesth Crit Care . 2007:7(4):107–11.
  10. Kellum JA. Determinants of blood pH in health and disease. Crit Care. 2000;4(1):6–14.
  11. Levraut J, Grimaud D. Treatment of metabolic acidosis. Curr Opin Crit Care. 2003;9:260–5
  12. Randall L, Begovic J, Hudson M, Smiley D, Peng L, Pitre N, et al. Recurrent diabetic ketoacidosis in inner-city minority patients: behavioral, socioeconomic, and psychosocial factors. Diabetes Care. 2011;34(9):1981–96.
  13. Price DA. Case study: recurrent diabetic ketoacidosis resulting from spurious hypoglycemia: a deleterious consequence of inadequate detection of partial strip filling by a glucose monitoring system. Clinical Diabetes. 2009;27(4):164–6.

Copyright (c) 2017 Dita Aditianingsih, Anne S. Djaja, Yohanes W.H. George

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

All articles and issues in Medical Journal of Indonesia have unique DOI number registered in Crossref.