Diabetic ketoacidosis: the speed of fluid replacement did not clearly affect biochemical improvement.

Clinical bottom line (level 1b-)

  1. In patients with diabetic ketoacidosis and no evidence of severe dehydration, normal saline given at 500 ml/hour for 4 hours followed by 250 ml/hour for 4 hours, did not clearly improve biochemistry more slowly than normal saline 1 L/hour for 4 hours followed by 500 ml/hr for 4 hours.
Adrogue et al: Journal of the American Medical Association 1989; 262: 2108-2113
Expires October 2003

The study

Unblinded concealed randomised trial without intention-to-treat
Setting: veterans' affairs hospital and university hospital, USA

23 patients (aged range 16 to 57 years; mean 32, 52% male) severe diabetic ketoacidosis (defined as glucose >14 mmol/l, ketonaemia and bicarbonate 12 mmol/l or less)

Excluded if
  • circulatory shock
  • oliguria (<30 ml/hr) during the first 4 hours of admission
  • renal insufficiency (urea >21 mmol/l or creatinine >350 µ mol/l)


    • Control Group: (n = , 12 analysed): high rate infusion: normal saline 1 L/hour for 4 hours; 500 ml/hr for 4 hours; then oral fluids and iv fluids according to oral intake
    Experimental Group: (n = , 11 analysed): low rate infusion: normal saline 500 ml/hour for 4 hours; 250 ml/hour for 4 hours
    All patients received insulin 10 units bolus then 0.1 u/kg/hour iv infusion. Potassium supplementation was provided if necessary using the same protocol in both groups.
    100% followed for 24 hours

    The evidence

  • No difference between the two groups was noted in glucose, potassium, urea, creatinine, haematocrit, albumin, phosphate levels at any time.
  • Small differences were noted after 4 hours in sodium, and chloride levels (<10 mmol/l difference), but at no other time.

    • Comments

    1. Patients were randomised in pairs.
    2. No comments made about pulmonary or cerebral oedema in either group.
    3. Small numbers, short follow-up and failure to report any clinical outcomes make these results uncertain.
    4. Unresolved as yet is the debate about whether to use normal saline (0.9%) or half-normal saline (0.45%) as the replacement vehicle of choice.

    Citation

    1. Adrogue HJ, Barrero J, Eknoyan G: Salutary effects of modest fluid replacement in the treatment of adults with diabetic ketoacidosis. Use in patients without extreme volume deficit. Journal of the American Medical Association 1989; 262: 2108-2113
    Contributor: Richard Hardern and Chris Ball, July 2000
    Reviewer: Jon Levine

    Clinical Question.
    Patient DKA
    Intervention or Exposure rate of saline delivery
    Outcome biochemistry improvement