Saline or Lactated Ringers/Plasma-lyte for DKA Resuscitation?

When patients present to the ED in DKA, should we resuscitate them with 0.9% sodium chloride (saline) or balanced salt solutions such as plasma-lyte or lactated ringers?
Many DKA order sets use 0.9% sodium chloride “aka normal saline” as their initial fluid of choice.
We know these patients are dry when they arrive to the ED.
They need significant amounts of fluid to be appropriately resuscitated.
If you’re curious of the contents of saline, LR, and plasma-lyte, I’ve created individual videos about all three.
Which fluid is the best for DKA patients, though?
In January of 2022 a systematic review and meta-analysis was performed and published in an attempt to answer this question.
It is free for you to download and I recommend you read the article for yourself.
This is not medical advice.
They included 8 randomized controlled trials with a total of 492 patients.
The findings were not favorable to normal saline.
Turns out that patients on saline take longer to get out of DKA rather than balanced salt solutions.
They also spend a longer period of time in the hospital.
They develop a hyperchloremic metabolic acidosis
Also, their serum bicarb takes longer to normalize.
Is it time to revisit our DKA protocols and adjust the fluids based on these data?
I think it is.

Citation for Fluids in DKA: Saline, or Lactated Ringers/Plasma-lyte

Alghamdi NA, Major P, Chaudhuri D, Tsui J, Brown B, Self WH, Semler MW, Ramanan M, Rochwerg B. Saline Compared to Balanced Crystalloid in Patients With Diabetic Ketoacidosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Explor. 2022 Jan 6;4(1):e0613. doi: 10.1097/CCE.0000000000000613. PMID: 35018349; PMCID: PMC8740878.
Link to Article

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