Balanced electrolyte solutions versus isotonic saline in adult patients with diabetic ketoacidosis: A systematic review and meta-analysis

• The use of balanced electrolyte solutions among patients with moderate to severe DKA is associated with faster resolution compared to isotonic saline.

• Time to event analysis for the resolution of DKA adjusted for possible confounders such as baseline bicarbonate and volume of IV fluids are needed for future studies.

Abstract

Background

Current guidelines suggest the use of isotonic saline (IS) infusion as the preferred resuscitation fluid in the management of diabetic ketoacidosis (DKA). However, balanced electrolyte solutions (BES) have been proposed as an alternative due to a lower propensity to cause hyperchloremic metabolic acidosis. Evidence regarding the use of BES in DKA remains limited.

Objectives

To determine if the use of BES in fluid resuscitation leads to faster resolution of DKA compared to IS.

Methods

The study involves a comprehensive search of literature from PubMed, Cochrane CENTRAL, Google Scholar, and Science Direct of clinical trials addressing the use of BES vs IS in fluid resuscitation in DKA. The time to resolution of DKA was examined as the primary endpoint. Pooled hazard ratios (HR) and Mean Difference (MD) in hours with their 95% confidence intervals (CI) were calculated using a random-effects model.

Results

The literature search included 464 studies that were screened individually. A total of 9 studies were identified but 6 studies were excluded due to irrelevance in the outcome of interest and target population. The pooled hazard ratio HR significantly revealed 1.46 [1.10 to 1.94] ( p = 0.009) with 12% heterogeneity while MD was -3.02 (95% CI -6.78–0.74; p = 0.12) with heterogeneity of 85%.

Conclusion

Considering the evidence from pooled small randomized trials with moderate overall certainty of evidence, the use of BES in DKA was associated with faster rates of DKA resolution compared to IS.