The effect of balanced electrolyte solution versus normal saline in the prevention of hyperchloremic metabolic acidosis in diabetic ketoacidosis patients: a randomized controlled trial
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 resuscitationâs result indicator and strong ion difference (SID) to measure chlorideâs 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 RingerfundinÃ (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 (-4.88Â±5.69 vs -9.68Â±5.64; p=0.009), 24 hours (-3.99Â±4.27 vs -8.7Â±5.35; p=0.023), and 48 hours (-4.06Â±4.11 vs -7.01Â±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.
Kitabchi AE, Umpirezz GE, Miles JM, Fisher JN. Hyperglycemic crisis in adult patients with diabetes. Diabetes Care. 2009;32(7):1335-43. https://doi.org/10.2337/dc09-9032
Diabetes.org.uk [Internet]. Joint british diabetes societies inpatient care group. The management of diabetic ketoacidosis in adult [update: 2013 Sep; cited 2014 Nov]. Available from: http://www.diabetes.org.uk/Documents/Adults/Guidelines.htm.)
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. https://doi.org/10.1097/00000542-199905000-00007
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. https://doi.org/10.1016/j.ajem.2010.02.004
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. https://doi.org/10.1093/qjmed/hcr226
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. https://doi.org/10.1590/S0103-507X2007000400006
Stewart PA. Modern quantitative acid-base chemistry. Can J Physiol Pharmacol. 1983;61(12):1444-61. https://doi.org/10.1139/y83-207
Bellomo R, Naka T, Baldwin I. Intravenous fluids and acid base balance. Contrib Nephrol. 2004;144:105-18. https://doi.org/10.1159/000078881
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. https://doi.org/10.1093/bjaceaccp/mkm019
Kellum JA. Determinants of blood pH in health and disease. Crit Care. 2000;4(1):6-14. https://doi.org/10.1186/cc644
Levraut J, Grimaud D. Treatment of metabolic acidosis. Curr Opin Crit Care. 2003;9:260-5 https://doi.org/10.1097/00075198-200308000-00002
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. https://doi.org/10.2337/dc11-0701
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. https://doi.org/10.2337/diaclin.27.4.164
Copyright (c) 2017 Dita Aditianingsih, Anne S. Djaja, Yohanes W.H. George
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Authors who publish with Medical Journal of Indonesia agree to the following terms:
- Authors retain copyright and grant Medical Journal of Indonesia right of first publication with the work simultaneously licensed under a Creative Commons Attribution-NonCommercial License that allows others to remix, adapt, build upon the work non-commercially with an acknowledgment of the work’s authorship and initial publication in Medical Journal of Indonesia.
- Authors are permitted to copy and redistribute the journal's published version of the work non-commercially (e.g., post it to an institutional repository or publish it in a book), with an acknowledgment of its initial publication in Medical Journal of Indonesia.