Crystalloid solutions provide faster resolution of DKA than saline: RCT

Balanced crystalloid therapy leads to faster resolution of DKA than saline, according to new evidence.

A subgroup analysis of the SALT-ED and SMART studies of fluid management in non-critically ill and critically ill adults focussed on patients presenting with DKA.

The 172 patients in the DKA analysis had a median age of 29 years and most were in DKA due to a missed medication dose. 94 had received either Lactated Ringer’s or Plasma-Lyte and 78 received saline for volume expansion.

The US study, published in JAMA Network Open, found that time to DKA resolution was shorter with the balanced crystalloids than saline (13.0 v 16.9 hours; p = 0.002).

Median time to insulin drip discontinuation was also shorter in the balanced crystalloids group than in the saline group (9.8 v 13.4 hours; p = 0.04)

Fewer patients experienced hypokalaemia in the balanced crystalloids group compared to the saline group but other clinical outcomes were similar.

“According to the median values, balanced crystalloids were associated with an absolute reduction of approximately 4 hours and a relative reduction of approximately 20% to 30% in the time to DKA resolution and discontinuation of insulin infusion,” the study said.

“These results suggest that balanced crystalloids may be preferred over saline for the acute management of adults with DKA.”

Yet the study noted that current DKA clinical practice guidelines recommend saline as the fluid of choice for volume.

“We believe that the results of this study add to the accumulating evidence suggesting balanced crystalloids are better resuscitation fluids than saline for many patients and may have particular benefits for patients with DKA.”

They said both options were readily available and similar in cost.

“Therefore, no particular barrier exists to optimizing clinical care for DKA patients by incorporating use of balanced crystalloids. Consistent implementation of interventions that deliver small improvements in outcomes for common conditions can translate into substantial improvements in population health and health system function.”

The study noted a recent trial of saline versus Plasma-Lyte in children had found the times to resolution of DKA were similar in both groups.

Paediatric endocrinologist Professor Maria Craig leads a review of the ISPAD guidelines which are likely to be released in 2022.

ISPAD guidelines already say you can use either [type of fluid] for the replacement and that is partly because of the hyperchloremic acidosis that you get from giving a lot of saline.”

However normal saline was readily available, easy to give and has been standard practice.

“People don’t want to change practice unless they have got good evidence to do so and I guess this is the first trial that has actually done this. This is new information that may perhaps strengthen the argument to use Plasma-Lyte.”

“Most paediatric endocrinologists would say that you shouldn’t be extrapolating from adults to children but it’s an interesting study and as they said, the biggest issue with giving big volumes of normal saline is this excess chloride.”

“My feeling is this new study could be cautiously adopted in young people,” she said

Professor Craig, from the Children’s Hospital at Westmead, said one issue might be accessibility to crystalloid solutions particularly in remote centres.

And it was not clear whether the three to four hour difference in time to DKA resolution depending on the type of fluid was clinically meaningful.

“The time difference is not huge but we are talking about a large patient population. It is good that an RCT has been done. The findings of the study make biological sense.”

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