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0.9% Saline versus Ringer's lactate as initial fluid in children with diabetic ketoacidosis: a double-blind
Ashish Agarwal1, Muralidharan Jayashree2, Karthi Nallasamy1
1Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, Punjab and Haryana, India.
Insights
Ringer's lactate (RL) significantly reduced diabetic ketoacidosis (DKA) resolution time in children compared to 0.9% saline (NS). RL also led to lower chloride levels and higher bicarbonate, making it a favorable fluid choice for DKA treatment.
Area of Science:
- Pediatric Endocrinology
- Critical Care Medicine
- Fluid Resuscitation
Background:
- Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus (T1DM).
- 0.9% saline (NS) can cause hyperchloremia, potentially delaying DKA resolution.
- Ringer's lactate (RL) may improve DKA outcomes due to its bicarbonate-regenerating properties.
Purpose of the Study:
- To compare the efficacy of Ringer's lactate (RL) versus 0.9% saline (NS) in resolving DKA in children.
- To evaluate the impact of RL and NS on serum chloride and bicarbonate levels during DKA treatment.
Main Methods:
- A double-blind randomized controlled trial involving children (9 months to 12 years) with T1DM presenting in DKA.
- Participants received either NS or RL for initial resuscitation and fluid replacement.
- Primary outcome was time to DKA resolution; secondary outcomes included biochemical changes and acute kidney injury incidence.
Main Results:
- Sixty-seven children were randomized (34 to NS, 33 to RL).
- Mean DKA resolution time was shorter in the RL group (12.9 hours) compared to the NS group (16.8 hours).
- RL group showed a smaller increase in serum chloride and a greater increase in serum bicarbonate compared to the NS group.
Conclusions:
- Ringer's lactate (RL) administration resulted in a shorter time to diabetic ketoacidosis (DKA) resolution in pediatric patients.
- RL's ability to regenerate bicarbonate, unlike NS which causes hyperchloremia, provides a physiological advantage.
- RL is a favorable fluid resuscitation option for children experiencing DKA.
Introduction:
Ringer's lactate (RL), a balanced crystalloid by regenerating bicarbonate ion, may lead to early diabetic ketoacidosis (DKA) resolution and reduced hyperchloremia as compared with 0.9% saline (NS).
Research Design And Methods:
This was a double-blind randomized controlled trial conducted in the pediatric emergency and intensive care units of a teaching hospital. Children with type 1 diabetes mellitus (T1DM) aged 9 months to 12 years who presented in DKA were included. Participants were randomized to receive either NS or RL as initial fluid (used for both resuscitation and replacement). The primary outcome was time to resolution of DKA. Secondary outcomes included change in serum chloride and bicarbonate from baseline, total fluid received and incidence of acute kidney injury.
Results:
The study was conducted between December 2020 and December 2021, and 67 children were recruited (34 in the NS group and 33 in the RL group). The mean time to DKA resolution was shorter in the RL group compared with the NS group (12.9±7.9 vs 16.8±9 hours). The mean difference and HR for time to DKA resolution in the RL group compared with the NS group were 3.85 hours (95% CI 0.3 to 8) and 1.39 hours (95% CI 1.25 to 1.56), respectively. The rise in chloride from baseline was higher in the NS group as compared with the RL group at 4 and 8 hours (8.7±5.6 vs 3.9±5.1 mmol/L) and (10.8±7.7 vs 4.4±8.3 mmol/L), respectively. On the contrary, the rise in bicarbonate from baseline to 12 hours was significantly higher in the RL group as compared with the NS group (14.7±1.6 vs 12.9±3.1).
Conclusions:
The time to resolution of DKA was shorter in RL group as compared with the NS group. Regeneration of bicarbonate from lactate ion in the RL forms a strong physiological basis for this outcome as compared with hyperchloremia induced by NS. This makes RL a favorable option in children with DKA.
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