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Liu Y, Zhang J, Xu X, Zou X. Comparison of balanced crystalloids versus normal saline in patients with diabetic ketoacidosis: a meta-analysis of randomized controlled trials. Front Endocrinol (Lausanne) 2024; 15:1367916. [PMID: 38836222 PMCID: PMC11148269 DOI: 10.3389/fendo.2024.1367916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 05/03/2024] [Indexed: 06/06/2024] Open
Abstract
Purpose The optimal resuscitative fluid for patients with diabetic ketoacidosis (DKA) remains controversial. Therefore, our objective was to assess the effect of balanced crystalloids in contrast to normal saline on clinical outcomes among patients with DKA. Methods We searched electronic databases for randomized controlled trials comparing balanced crystalloids versus normal saline in patients with DKA, the search period was from inception through October 20th, 2023. The outcomes were the time to resolution of DKA, major adverse kidney events, post-resuscitation chloride, and incidence of hypokalemia. Results Our meta-analysis encompassed 11 trials, incorporating a total of 753 patients with DKA. There was no significant difference between balanced crystalloids and normal saline group for the time to resolution of DKA (MD -1.49, 95%CI -4.29 to 1.31, P=0.30, I2 = 65%), major adverse kidney events (RR 0.88, 95%CI 0.58 to 1.34, P=0.56, I2 = 0%), and incidence of hypokalemia (RR 0.80, 95%CI 0.43 to 1.46, P=0.46, I2 = 56%). However, there was a significant reduction in the post-resuscitation chloride (MD -3.16, 95%CI -5.82 to -0.49, P=0.02, I2 = 73%) among patients received balanced crystalloids. Conclusion Among patients with DKA, the use of balanced crystalloids as compared to normal saline has no effect on the time to resolution of DKA, major adverse kidney events, and incidence of hypokalemia. However, the use of balanced crystalloids could reduce the post-resuscitation chloride. Systematic review registration https://osf.io, identifier c8f3d.
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Affiliation(s)
- Yuting Liu
- Oncology and Chemotherapy Department, Lishui People’s Hospital, Lishui, China
| | - Jianfeng Zhang
- Department of Orthopedics, Yunhe People’s Hospital, Lishui, China
| | - Xiaoya Xu
- Department of General Surgery, Lishui People’s Hospital, Lishui, China
| | - Xiaoyun Zou
- Department of General Practice, Lishui Central Hospital, Lishui, China
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2
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Hay RE, Parsons SJ, Wade AW. The effect of dehydration, hyperchloremia and volume of fluid resuscitation on acute kidney injury in children admitted to hospital with diabetic ketoacidosis. Pediatr Nephrol 2024; 39:889-896. [PMID: 37733096 DOI: 10.1007/s00467-023-06152-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/18/2023] [Accepted: 08/23/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a recognized comorbidity in pediatric diabetic ketoacidosis (DKA), although the exact etiology is unclear. The unique physiology of DKA makes dehydration assessments challenging, and these patients potentially receive excessive amounts of intravenous fluids (IVF). We hypothesized that dehydration is over-estimated in pediatric DKA, leading to over-administration of IVF and hyperchloremia that worsens AKI. METHODS Retrospective cohort of all DKA inpatients at a tertiary pediatric hospital from 2014 to 2019. A total of 145 children were included; reasons for exclusion were pre-existing kidney disease or incomplete medical records. AKI was determined by change in creatinine during admission, and comparison to a calculated baseline value. Linear regression multivariable analysis was used to identify factors associated with AKI. True dehydration was calculated from patients' change in weight, as previously validated. Fluid over-resuscitation was defined as total fluids given above the true dehydration. RESULTS A total of 19% of patients met KDIGO serum creatinine criteria for AKI on admission. Only 2% had AKI on hospital discharge. True dehydration and high serum urea levels were associated with high serum creatinine levels on admission (p = 0.042; p < 0.001, respectively). Fluid over-resuscitation and hyperchloremia were associated with delayed kidney recovery (p < 0.001). Severity of initial AKI was associated with cerebral edema (p = 0.018). CONCLUSIONS Dehydration was associated with initial AKI in children with DKA. Persistent AKI and delay to recovery was associated with hyperchloremia and over-resuscitation with IVF, potentially modifiable clinical variables for earlier AKI recovery and reduction in long-term morbidity. This highlights the need to re-address fluid protocols in pediatric DKA.
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Affiliation(s)
- Rebecca E Hay
- Department of Pediatrics, Faculty of Medicine, University of Calgary, Calgary, Canada.
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada.
| | - Simon J Parsons
- Department of Pediatrics, Faculty of Medicine, University of Calgary, Calgary, Canada
- Section of Critical Care, Department of Pediatrics, Faculty of Medicine, University of Calgary, Alberta Children's Hospital, Calgary, Canada
| | - Andrew W Wade
- Department of Pediatrics, Faculty of Medicine, University of Calgary, Calgary, Canada
- Section of Nephrology, Department of Pediatrics, Faculty of Medicine, University of Calgary, Alberta Children's Hospital, Calgary, Canada
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Gilchrist HE, Hatton CJ, Roginski MA, Esteves AM. Impact on Diabetic Ketoacidosis Resolution After Implementation of a 2-Bag Fluid Order Set. Ann Pharmacother 2023; 57:1361-1366. [PMID: 37021360 DOI: 10.1177/10600280231163838] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is a serious acute complication of both type 1 and type 2 diabetes that requires prompt management. Limited data exist supporting the use of a 2-bag DKA protocol in adult patients across all levels of care. OBJECTIVE To evaluate the efficacy and safety of a 2-bag DKA protocol in comparison with a traditional DKA management strategy. METHODS Retrospective review of patients admitted with DKA between January 1, 2021, and February 28, 2022, at a single center. Patients were separated into 2 cohorts, traditional or 2-bag. The primary outcome was time to anion gap closure and/or beta-hydroxybutyrate normalization. Secondary outcomes include length of hospitalization, insulin infusion time, and hypoglycemic events. RESULTS One hundred forty-three patients had a DKA order set initiated during their admission, 59 in the traditional cohort and 84 in the 2-bag cohort. Mean time to anion gap closure was shorter in the 2-bag cohort (12.7 vs 16.9 hours; P = 0.005) and beta-hydroxybutyrate normalization (15.6 vs 25.6 hours; P = 0.026). No difference in hospital length of stay (4 vs 6 days; P = 0.113), duration of insulin infusion (41.6 vs 40.6 hours; P = 0.455), or rates of hypoglycemia (6 vs 4; P = 0.872) was seen. CONCLUSION AND RELEVANCE Implementation of a 2-bag DKA protocol in the inpatient setting was associated with a shorter time to anion gap closure and beta-hydroxybutyrate normalization. These findings support the option of expansion of a 2-bag DKA protocol to adult patients across all levels of care irrespective of the admission diagnosis.
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Affiliation(s)
- Hannah E Gilchrist
- Department of Pharmacy, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Colman J Hatton
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Matthew A Roginski
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Alyson M Esteves
- Department of Pharmacy, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Chen Y, Gao Y. Comparison of Balanced Crystalloids versus Normal Saline in Critically Ill Patients: A Systematic Review with Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials. Ther Clin Risk Manag 2023; 19:783-799. [PMID: 37850070 PMCID: PMC10577264 DOI: 10.2147/tcrm.s416785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/25/2023] [Indexed: 10/19/2023] Open
Abstract
Background Fluid resuscitation is routinely needed for critically ill patients. However, the optimal choice between crystalloids and normal saline is in heat debate. Objective To conduct a meta-analysis comparing normal saline and balanced crystalloids in the treatment of critically ill patients with composite mortality as the primary outcome. Methods PubMed, Embase, Medline, Web of Science, and Cochrane Library were searched from inception up to March 2022. Studies of critically ill adult patients assigned to receive normal saline or balanced crystalloids were included. We conducted a meta-analysis using an inverse variance, random-effects model in addition to trial sequential analysis (TSA). The primary outcome was composite mortality. Subgroup analyses were also conducted. Results Eighteen full-text studies (n=36,224) were included. Balanced crystalloids were associated with lower mortality compared with normal saline (risk ratio [RR]=0.96; 95% confidential interval [CI] 0.93, 1; p=0.03; I2=0) and lower incidence of acute kidney injury/acute renal failure (RR =0.93; 95% CI = 0.87, 0.99; p=0.03). No significant difference was observed in other outcomes. In the sepsis patients, the balanced crystalloid showed a lower composite mortality rate compared with normal saline (RR =0.91; 95% CI = 0.85, 0.99; p=0.02). TSA analysis demonstrated that, with 80% power, the effect of balanced crystalloid is not larger than a 10% relative decrease in composite mortality compared with normal saline. Conclusion and Relevance This study demonstrated that balanced crystalloids could be an optimal choice over normal saline in critically ill patients to a reduced composite mortality rate. In patients with sepsis, the difference is especially significant. Nonetheless, the optimal resuscitation fluid option between saline and balanced crystalloid solutions should be investigated further with more evidence.
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Affiliation(s)
- Yi Chen
- Emergency Department of West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu City, Sichuan Province, People’s Republic of China
- Institute of Disaster Medicine, Sichuan University, Chengdu City, Sichuan Province, People’s Republic of China
- Nursing Key Laboratory of Sichuan Province, Chengdu City, Sichuan Province, People’s Republic of China
| | - Yongli Gao
- Emergency Department of West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu City, Sichuan Province, People’s Republic of China
- Institute of Disaster Medicine, Sichuan University, Chengdu City, Sichuan Province, People’s Republic of China
- Nursing Key Laboratory of Sichuan Province, Chengdu City, Sichuan Province, People’s Republic of China
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Shaw JF, Ouyang Y, Fergusson DA, McArdle T, Martin C, Cook D, Graham ID, Hawken S, McCartney CJL, Menon K, Saginur R, Seely A, Stiell I, Fox-Robichaud A, English S, Marshall J, Thavorn K, Taljaard M, McIntyre LA. A Hospital-Wide Open-Label Cluster Crossover Pragmatic Comparative Effectiveness Randomized Trial Comparing Normal Saline to Ringer's Lactate: Protocol and Statistical Analysis Plan of The FLUID Trial. JMIR Res Protoc 2023; 12:e51783. [PMID: 37801356 PMCID: PMC10589831 DOI: 10.2196/51783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Normal saline (NS) and Ringer's lactate (RL) are the most common crystalloids given to hospitalized patients. Despite concern about possible harm associated with NS (eg, hyperchloremic metabolic acidosis, impaired kidney function, and death), few large multicenter randomized trials focused on critically ill patients have compared these fluids. Uncertainty exists about the effects of these fluids on clinically important outcomes across all hospitalized patients. OBJECTIVE The FLUID trial is a pragmatic, multicenter, 2×2 cluster crossover comparative effectiveness randomized trial that aims to evaluate the effectiveness of a hospital-wide policy that stocks either NS or RL as the main crystalloid fluid in 16 hospitals across Ontario, Canada. METHODS All hospitalized adult and pediatric patients (anticipated sample size 144,000 patients) with an incident admission to the hospital over the course of each study period will be included. Either NS or RL will be preferentially stocked throughout the hospital for 12 weeks before crossing to the alternate fluid for the subsequent 12 weeks. The primary outcome is a composite of death and hospital readmission within 90 days of hospitalization. Secondary outcomes include death, hospital readmission, dialysis, reoperation, postoperative reintubation, length of hospital stay, emergency department visits, and discharge to a facility other than home. All outcomes will be obtained from health administrative data, eliminating the need for individual case reports. The primary analysis will use cluster-level summaries to estimate cluster-average treatment effects. RESULTS The statistical analysis plan has been prepared "a priori" in advance of receipt of the trial data set from ICES and any analyses. CONCLUSIONS We describe the protocol and statistical analysis plan for the evaluation of primary and secondary outcomes for the FLUID trial. TRIAL REGISTRATION ClinicalTrials.gov NCT04512950; https://classic.clinicaltrials.gov/ct2/show/NCT04512950. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/51783.
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Affiliation(s)
- Julia F Shaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Yongdong Ouyang
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Tracy McArdle
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Claudio Martin
- Division of Critical Care Medicine, London Health Sciences Centre, Western University, London, ON, Canada
| | - Deborah Cook
- Departments of Medicine, Clinical Epidemiology and Biostatistics, St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, ON, Canada
| | - Ian D Graham
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Steven Hawken
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- ICES, University of Ottawa, Ottawa, ON, Canada
| | | | - Kusum Menon
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Raphael Saginur
- Department of Medicine, Infectious Diseases, The Ottawa Hospital, Ottawa, ON, Canada
| | - Andrew Seely
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Ian Stiell
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Alison Fox-Robichaud
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Shane English
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Department of Medicine, Division of Critical Care, University of Ottawa, Ottawa, ON, Canada
| | - John Marshall
- Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- ICES, University of Ottawa, Ottawa, ON, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Lauralyn A McIntyre
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Department of Medicine, Division of Critical Care, University of Ottawa, Ottawa, ON, Canada
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6
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Management of diabetic ketoacidosis. Intensive Care Med 2023; 49:95-98. [PMID: 36166056 DOI: 10.1007/s00134-022-06894-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/14/2022] [Indexed: 01/24/2023]
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7
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Plasma volume expansion reveals hidden metabolic acidosis in patients with diabetic ketoacidosis. Intensive Care Med Exp 2022; 10:36. [PMID: 36038699 PMCID: PMC9424448 DOI: 10.1186/s40635-022-00464-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/13/2022] [Indexed: 11/30/2022] Open
Abstract
Background Hyperchloremic metabolic acidosis that develops during the treatment of diabetic ketoacidosis is usually attributed to the chloride content of resuscitation fluids. We explored an alternative explanation, namely that fluid-induced plasma volume expansion alters the absolute differences in the concentrations of sodium and chloride (the Na–Cl gap) enough to affect the acid–base balance. We analyzed data from a prospective single-center cohort study of 14 patients treated for diabetic ketoacidosis. All patients received 1 L of 0.9% saline over 30 min on two consecutive days. Blood gases were sampled before and after the infusions. Results The initial plasma volume was estimated to be 25 ± 13% (mean ± SD) below normal on admission to the intensive care unit. At that time, most patients had an increased actual Na–Cl gap, which counteracts acidosis. However, the correction of the plasma volume deficit revealed that these patients would have had a decreased Na–Cl gap upon admission if they had been normovolemic at that time; the estimated “virtual Na–Cl gap” of 29 ± 5 mmol/L was significantly lower than the uncorrected value, which was 39 ± 5 mmol/L (P < 0.001). On Day 2, most patients had a decreased actual Na–Cl gap (33 ± 5 mmol/L), approaching the corrected value on Day 1. Conclusions The hyperchloremic acidosis commonly seen in diabetic ketoacidosis may not be primarily caused by the chloride content of resuscitation fluids but, rather, by the restoration of plasma volume, which reveals the hidden metabolic acidosis caused by a decreased Na–Cl gap. Trial registration Clinical Trials Identifier NCT02172092, registered June 24, 2014, https://www.clinicaltrials.gov/NCT02172092 Supplementary Information The online version contains supplementary material available at 10.1186/s40635-022-00464-5.
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Kopp BJ, Lenney M, Erstad BL. Balanced Salt Solutions for Critically Ill Patients: Nonplused and Back to Basics. Ann Pharmacother 2022; 56:1365-1375. [PMID: 35392676 DOI: 10.1177/10600280221084380] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVES The purpose of this article is to summarize the results of major randomized controlled trials (RCTs) comparing clinical outcomes of critically ill patients treated with normal saline (NS) or balanced salt solutions (BSSs), address discordant results of these studies, and provide direction for future investigations. DATA SOURCES PubMed (2011 to January 2022) with bibliographies of retrieved articles searched for additional articles. STUDY SELECTION AND DATA EXTRACTION RCTs comparing NS and BSSs in critically ill adult patients. DATA SYNTHESIS Recently published large RCTs comparing NS with BSSs in heterogeneous populations of intensive care unit patients did not find significant differences in mortality, despite positive findings in some end points in prior RCTs. However, there were a number of methodologic issues common to the RCTs including: varying study designs and end points, clinician discretion for the majority or all treatments other than the primary intervention fluid, heterogeneous patients with varying levels of acuity, and lack of power to investigate potential subgroup differences. In addition, there were problematic issues related to blinding and use of nonstudy fluids. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Intravenous fluids are a mainstay of supportive care for critically ill patients. Similar to the so-called crystalloid-colloid debate, there has been a long-standing debate among critical care clinicians and researchers concerning the preferred crystalloid solution, NS versus one of the available BSSs. CONCLUSIONS Despite the recent publication of large multicenter RCTs, the preferred resuscitation fluid, NS or a BSS, for critically ill patients is still open for debate, although the available investigations do provide some direction for clinicians and for future investigations.
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Affiliation(s)
- Brian J Kopp
- Surgical-Trauma ICU, Banner-University Medical Center, Tucson, AZ, USA
| | - Morgan Lenney
- PGY2 Critical Care Resident, Banner-University Medical Center, Tucson, AZ, USA
| | - Brian L Erstad
- Department of Pharmacy Practice & Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA
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9
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Diabetische Ketoazidose: Vollelektrolytlösung oder 0,9%ige Kochsalzlösung? Anasthesiol Intensivmed Notfallmed Schmerzther 2022. [DOI: 10.1055/a-1819-5623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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10
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Aldhaeefi M, Aldardeer NF, Alkhani N, Alqarni SM, Alhammad AM, Alshaya AI. Updates in the Management of Hyperglycemic Crisis. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2022; 2:820728. [PMID: 36994324 PMCID: PMC10012093 DOI: 10.3389/fcdhc.2021.820728] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/24/2021] [Indexed: 12/14/2022]
Abstract
Diabetes mellitus (DM) affects the metabolism of primary macronutrients such as proteins, fats, and carbohydrates. Due to the high prevalence of DM, emergency admissions for hyperglycemic crisis, diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are fairly common and represent very challenging clinical management in practice. DKA and HHS are associated with high mortality rates if left not treated. The mortality rate for patients with DKA is < 1% and ~ 15% for HHS. DKA and HHS have similar pathophysiology with some few differences. HHS pathophysiology is not fully understood. However, an absolute or relative effective insulin concentration reduction and increased in catecholamines, cortisol, glucagon, and growth hormones represent the mainstay behind DKA pathophysiology. Reviewing the patient’s history to identify and modify any modifiable precipitating factors is crucial to prevent future events. The aim of this review article is to provide a review of the DKA, and HHS management based on the most recently published evidence and to provide suggested management pathway of DKA of HHS management in practice.
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Affiliation(s)
- Mohammed Aldhaeefi
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- *Correspondence: Mohammed Aldhaeefi,
| | - Namareq F. Aldardeer
- Department of Pharmacy Services, King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia
| | - Nada Alkhani
- Department of Pharmacy Services, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Shatha Mohammed Alqarni
- Doctor of Pharmacy Program, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdullah M. Alhammad
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Department of Pharmacy Services, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Abdulrahman I. Alshaya
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Hammond NE, Zampieri FG, Di Tanna GL, Garside T, Adigbli D, Cavalcanti AB, Machado FR, Micallef S, Myburgh J, Ramanan M, Rice TW, Semler MW, Young PJ, Venkatesh B, Finfer S, Delaney A. Balanced Crystalloids versus Saline in Critically Ill Adults - A Systematic Review with Meta-Analysis. NEJM EVIDENCE 2022; 1:EVIDoa2100010. [PMID: 38319180 DOI: 10.1056/evidoa2100010] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
BACKGROUND: The comparative efficacy and safety of balanced crystalloid solutions and saline for fluid therapy in critically ill adults remain uncertain. METHODS: We systematically reviewed randomized clinical trials (RCTs) comparing the use of balanced crystalloids with saline in critically ill adults. The primary outcome was 90-day mortality after pooling data from low-risk-of-bias trials using a random-effects model. We also performed a Bayesian meta-analysis to describe the primary treatment effect in probability terms. Secondary outcomes included the incidence of acute kidney injury (AKI), new treatment with renal replacement therapy (RRT), and ventilator-free and vasopressor-free days to day 28. RESULTS: We identified 13 RCTs, comprising 35,884 participants. From six trials (34,450 participants) with a low risk of bias, the risk ratio (RR) for 90-day mortality with balanced crystalloids versus saline was 0.96 (95% confidence interval [CI], 0.91 to 1.01; I2 = 12.1%); using vague priors, the posterior probability that balanced crystalloids reduce mortality was 89.5%. The RRs of developing AKI and of being treated with RRT with balanced crystalloids versus saline were 0.96 (95% CI, 0.89 to 1.02) and 0.95 (95% CI, 0.81 to 1.11), respectively. Ventilator-free days (mean difference, 0.18 days; 95% CI, −0.45 to 0.81) and vasopressor-free days (mean difference, 0.19 days; 95% CI, −0.14 to 0.51) were similar between groups. CONCLUSIONS: The estimated effect of using balanced crystalloids versus saline in critically ill adults ranges from a 9% relative reduction to a 1% relative increase in the risk of death, with a high probability that the average effect of using balanced crystalloids is to reduce mortality. (PROSPERO number, CRD42021243399.)
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Affiliation(s)
- Naomi E Hammond
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney
| | - Fernando G Zampieri
- HCor Research Institute, São Paulo
- D'Or Research and Education Institute, São Paulo
| | - Gian Luca Di Tanna
- BioStatistics and Data Science Division, Meta-Research and Evidence Synthesis, The George Institute for Global Health, University of New South Wales, Sydney
| | - Tessa Garside
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney
| | - Derick Adigbli
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney
| | | | - Flavia R Machado
- Anesthesiology, Pain, and Intensive Care Department, Federal University of São Paulo, São Paulo
| | - Sharon Micallef
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
| | - John Myburgh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Department of Intensive Care, St. George Hospital, Sydney
| | - Mahesh Ramanan
- Intensive Care Unit, Caboolture and The Prince Charles Hospitals, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, Queensland, Australia
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville
| | - Paul J Young
- Department of Intensive Care, Wellington Regional Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Balasubramanian Venkatesh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Intensive Care Unit, Wesley and Princess Alexandra Hospitals, Queensland, Australia
| | - Simon Finfer
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- School of Public Health, The George Institute for Global Health, Imperial College, London
| | - Anthony Delaney
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney
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Saline Compared to Balanced Crystalloid in Patients With Diabetic Ketoacidosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Explor 2022; 4:e0613. [PMID: 35018349 PMCID: PMC8740878 DOI: 10.1097/cce.0000000000000613] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES This systematic review and meta-analysis compared the use of saline to balanced crystalloid for fluid resuscitation in patients with diabetic ketoacidosis (DKA). DATA SOURCES We searched databases including Medline, Embase, and the Cochrane registry. STUDY SELECTION We included randomized controlled trials (RCTs) that compared saline to balanced crystalloid in patients with DKA. DATA EXTRACTION We pooled estimates of effect using relative risk for dichotomous outcomes and mean differences (MDs) for continuous outcomes, both with 95% CIs. We assessed risk of bias for included RCTs using the modified Cochrane tool and certainty of evidence using Grading of Recommendations, Assessment, Development, and Evaluation methodology. DATA SYNTHESIS We included eight RCTs (n = 482 patients). Both time to DKA resolution (MD, 3.51 hr longer; 95% CI, 0.90 longer to 6.12 longer; moderate certainty) and length of hospital stay (MD, 0.89 d longer in saline group; 95% CI, 0.34 longer to 1.43 d longer; moderate certainty) are probably longer in the saline group compared with the balanced crystalloid group, although for the latter, the absolute difference (under 1 d) is small. Post-resuscitation serum chloride level may be higher (MD, 1.62 mmol/L higher; 95% CI, 0.40 lower to 3.64 higher; low certainty), and post-resuscitation serum bicarbonate is probably lower (MD, 1.50 mmol/L; 95% CI, 2.33 lower to 0.67 lower; moderate certainty) in those receiving saline. CONCLUSIONS In patients with DKA, the use of saline may be associated with longer time to DKA resolution, higher post-resuscitation serum chloride levels, lower post-resuscitation serum bicarbonate levels, and longer hospital stay compared with balanced crystalloids. Pending further data, low to moderate certainty data support using balanced crystalloid over saline for fluid resuscitation in patients with DKA.
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Williams V, Mohandoss V. Portending Complications in Pediatric Diabetic Ketoacidosis. Indian J Crit Care Med 2021; 25:1339-1340. [PMID: 35027790 PMCID: PMC8693108 DOI: 10.5005/jp-journals-10071-24064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Williams V, Mohandoss V. Portending Complications in Pediatric Diabetic Ketoacidosis. Indian J Crit Care Med 2021;25(12):1339-1340.
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Affiliation(s)
- Vijai Williams
- Department of Critical Care, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Vichithra Mohandoss
- Department of Pediatrics, Saveetha Medical College and Hospital, Chennai, Tamil Nadu, India
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Fluid management in diabetic ketoacidosis: new tricks for old dogs? Intensive Care Med 2021; 47:1312-1314. [PMID: 34608527 DOI: 10.1007/s00134-021-06527-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/03/2021] [Indexed: 10/20/2022]
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