Hyperchloraemic metabolic acidosis slows recovery in children with diabetic ketoacidosis: a retrospective audit

0.9% Saline versus Ringer's lactate as initial fluid in children with diabetic ketoacidosis: a double-blind randomized controlled trial

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.

Hyperchloremia and Prolonged Acidosis During Treatment for Pediatric Diabetic Ketoacidosis

OBJECTIVES

Diabetic ketoacidosis (DKA) is characterized by metabolic acidosis with a high anion gap secondary to ketonemia. Intravenous hydration fluids used in treatment can cause chloride overload, leading to hyperchloremic metabolic acidosis (HMA). The development of HMA can lead to the persistence of acidosis despite the resolution of ketonemia.

METHODS

A total of 178 DKA episodes in 153 patients treated between January 2013 and October 2023 were included in the study. Creatine-based glomerular filtration rate and HbA1c value at admission and venous blood gas parameters (pH, actual bicarbonate, base deficit), anion gap, chloride-corrected bicarbonate, nonchloride base deficit, and sodium and chloride measured at 0, 2, 4, 6, 9, 12, 18 and 24 hours were evaluated.

RESULTS

Hyperchloremia was detected in 69.3% of participants and developed at a mean of 6.3 (±4.3) hours of treatment. The incidence of hyperchloremia increased with the duration of treatment; the rates were 8.4%, 51.3%, 65%, 76.2%, 75.5%, and 80% at 0, 6, 9, 12, 18, and 24 hours of treatment, respectively. The group with hyperchloremia had more severe acidosis, a higher HbA1c value, and a longer resolution time. At the 12th hour of treatment, acidosis continued based on pH and HCO 3 levels, whereas the hyperchloremia group exhibited a low anion gap (mean 12.8). At the 6th hour of treatment, the resolution rates were significantly lower in the hyperchloremia group based on the pH and HCO 3 levels but increased when assessed by chloride-corrected HCO 3 and anion gap.

CONCLUSIONS

During treatment of DKA, monitoring anion gap, blood ketones, and Cl - /Na + ratio or using regression equations in addition to routine acid-base parameters may help differentiate DKA from HMA and prevent prolonged intravenous treatment.

Comparing the clinical effects of balanced electrolyte solutions versus normal saline in managing diabetic ketoacidosis: A systematic review and meta-analyses

The first-line treatment of diabetes ketoacidosis (DKA) involves fluid resuscitation with normal saline infusion to correct hypovolemia. Hyperchloremic metabolic acidosis from aggressive normal saline administration was associated with worse clinical outcomes in managing DKA. Other choices for normal saline include balanced electrolyte solutions (BESs). This study aimed to compare the clinical effects between BESs and normal saline in managing DKA. This study was a systematic review of probing articles published from inception to October 2021 in Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online, Google Scholar, and Scopus. Eight randomized controlled trials with a total of 595 individuals were included. The data were analyzed at 95% confidence level using random-effects models. For the primary outcomes, there was no difference in the duration of DKA resolution. (Mean difference [MD] -4.73, 95% confidence interval [CI] -2.72-4.92; I² = 92%; P = 0.180). However, there was a significantly lower postresuscitation chloride concentration in the BES (MD 2.96 95% CI - 4.86 to - 1.06; I² = 59%; P = 0.002). For the secondary outcomes, there was a significant reduction in duration for normalization of bicarbonate in the BES group (MD 3.11 95% CI - 3.98-2.23; I² = 5%; P = 0.0004). There were no significant differences between groups in duration for recovery of pH, intensive unit admission, and adverse events (mortality and acute renal failure). Resuscitation with BES was associated with decreased chloride and increased bicarbonate values in DKA patients. It suggests that BES prevents DKA patients from hyperchloremic metabolic acidosis.

The role of anion gap normalization time in the management of pediatric diabetic ketoacidosis

Introduction

Our aims were to determine whether anion gap normalization time (AGNT) correlates with risk factors related to the severity of diabetic ketoacidosis (DKA) in children, and to characterize AGNT as a criterion for DKA resolution in children admitted with moderate or severe disease.

Methods

A ten-year retrospective cohort study of children admitted to the intensive care unit with DKA. We used a survival analysis approach to determine changes in serum glucose, bicarbonate, pH, and anion gap following admission. Using multivariate analysis, we examined associations between patients' demographic and laboratory characteristics with delayed normalization of the anion gap.

Results

A total of 95 patients were analyzed. The median AGNT was 8 h. Delayed AGNT (>8 h) correlated with pH < 7.1 and serum glucose >500 mg/dL. In multivariate analysis, glucose >500 mg/dL was associated with an increased risk for delayed AGNT, by 3.41 fold. Each 25 mg/dL elevation in glucose was associated with a 10% increment in risk for delayed AGNT. Median AGNT preceded median PICU discharge by 15 h (8 vs. 23 h).

Discussion

AGNT represents a return to normal glucose-based physiology and an improvement in dehydration. The correlation observed between delayed AGNT and markers of DKA severity supports the usefulness of AGNT for assessing DKA recovery.

Sodium chloride or Plasmalyte-148 evaluation in severe diabetic ketoacidosis (SCOPE-DKA): a cluster, crossover, randomized, controlled trial

PURPOSE

To determine whether treatment with Plasmalyte-148 (PL) compared to sodium chloride 0.9% (SC) results in faster resolution of diabetic ketoacidosis (DKA) and whether the acetate in PL potentiates ketosis.

METHODS

We conducted a cluster, crossover, open-label, randomized, controlled Phase 2 trial at seven hospitals in adults admitted to intensive care unit (ICU) with severe DKA with hospital randomised to PL or SC as fluid therapy. The primary outcome, DKA resolution, was defined as a change in base excess to ≥ - 3 mEq/L at 48 h.

RESULTS

Ninety-three patients were enrolled with 90 patients included in the modified-intention-to-treat population (PL n = 48, SC n = 42). At 48 h, mean fluid administration was 6798 ± 4850 ml vs 6574 ± 3123 ml, median anion gap 6 mEq/L (IQR 5-7) vs 7 mEq/L (IQR 5-7) and median blood ketones 0.3 mmol/L (IQR 0.1-0.5) vs 0.3 (IQR 0.1-0.5) in the PL and SC groups. DKA resolution at 48 h occurred in 96% (PL) and 86% (SC) of patients; odds ratio 3.93 (95% CI 0.73-21.16, p = 0.111). At 24 h, DKA resolution occurred in 69% (PL) and 36% (SC) of patients; odds ratio 4.24 (95% CI 1.68-10.72, p = 0.002). The median ICU and hospital lengths of stay were 49 h (IQR 23-72) vs 55 h (IQR 41-80) and 81 h (IQR 58-137) vs 98 h (IQR 65-195) in the PL and SC groups.

CONCLUSION

Plasmalyte-148, compared to sodium chloride 0.9%, may lead to faster resolution of metabolic acidosis in patients with DKA without an increase in ketosis. These findings need confirmation in a large, Phase 3 trial.

Resuscitation With Ringer's Lactate Compared With Normal Saline for Pediatric Diabetic Ketoacidosis

OBJECTIVE

The aims of this study were to describe the use of Ringer's lactate (LR) or normal saline (NS) for resuscitation among children with diabetic ketoacidosis (DKA) and compare the effect of fluid type on cost, length of stay, and rate of cerebral edema (CE).

METHODS

This is a retrospective study of 49,737 children aged 0 to 17 years with DKA between January 1, 2005, and September 30, 2015, using data from the Pediatric Health Information System. Treatment with LR or NS was identified. Our primary outcomes were total adjusted cost and length of stay. Our secondary outcome was CE rate per 1000 episodes.

RESULTS

The majority of patients were treated with NS (n = 43,841 [88%]) compared with LR (n = 1762 [4%]) or both NS and LR (n = 4134 [8%]). Hospital-year-specific practice patterns were used to investigate the effect of fluid type across resuscitation fluid groups. Total adjusted cost was $1160 less (95% confidence interval, -1468 to -852), or -14.2%, for cases with any episode of LR compared with NS only. Length of stay was not different across groups. The rate of cerebral edema per 1000 episodes was 12.7 for cases with any episode of LR compared with 34.6 NS only (difference, -21.9; 95% confidence interval, -30.4 to -13.3).

CONCLUSIONS

Ringer's lactate was infrequently used for resuscitation of pediatric DKA patients. However, resuscitation with LR compared with NS was associated with lower total cost and rates of CE. Further investigation using patient-level clinical and laboratory data is needed to evaluate factors that drive cost and risk of CE development with each fluid.

The Influence of Chloride for the Interpretation of Plasma Bicarbonate During the Treatment of Diabetic Ketoacidosis

INTRODUCTION

Hyperchloremic metabolic acidosis can occur in diabetic ketoacidosis (DKA) and may affect the acid-base interpretation during treatment.

OBJECTIVES

This study aims to describe the prevalence of hyperchloremia during the treatment of DKA and its effect on the interpretation of bicarbonate value.

METHODS

A cross-sectional study, including all cases of DKA in patients aged 1 to 18 years old admitted from 2010 to 2015, was performed. Laboratory tests were performed on admission (baseline), 2 and 6 hours after admission, and when resolution of DKA was achieved. Adjusted bicarbonate value was calculated using regression equations.

RESULTS

Seventy-nine DKA episodes were included. The average age was 13.3 ± 3.8 years. Baseline levels were as follows: plasma glucose, 479 ± 133 mg/dL; pH 7.1 ± 0.083; bicarbonate, 9.65 ± 2.9; and anion gap, 23.9 ± 7.5. The time to achieve resolution of DKA was 12.2 ± 4.4 hours, and the decrease in capillary glucose was 25.5 (19.7-38.2) mg/dL per hour. After 6 hours of treatment, the proportion of patients presenting hyperchloremia increased from 23% to 77%. By using adjusted bicarbonate, the percentage of patients achieving resolution of DKA after 6 hours of treatment would have been 35.4% (confidence interval 95%, 28-49), in comparison with 24.1% (confidence interval 95%, 18-37) using observed bicarbonate (P = 0.004).

CONCLUSIONS

The hyperchloremia developed during the treatment of DKA could modify the value of measured plasma bicarbonate concentration and unnecessarily prolong the initial phase of treatment.

Is lactic acidosis predictive of outcomes in pediatric diabetic ketoacidosis?

OBJECTIVES

The objective of this study was to investigate the significance and prevalence of lactic acidosis in pediatric diabetic ketoacidosis (DKA) presenting to the emergency department.

METHODS

A retrospective cohort study of children (age ≤ 21 years) presenting to a tertiary care emergency department in DKA from December 1, 2015 to December 1, 2018. Patients needed to have DKA requiring admission to the pediatric intensive care unit and have had a lactate level collected while in the emergency department to be included.

RESULTS

92 patients resulting in 113 encounters had DKA and a lactate level collected in the emergency department. The mean lactate level was 3.5 mmol/L (±SD 2.1). 72 (63.7%) encounters had lactic acidosis (p < 0.001). There was no significant association between the presence of lactic acidosis and pediatric intensive care unit length of stay (p = 0.321), hospital length of stay (p = 0.426), morbidity (p = 0.552) and mortality (p = 1.000). Initial glucose levels were significantly higher in the patients presenting with lactic acidosis (p = 0.001).

CONCLUSIONS

Lactic acidosis is a common finding in pediatric DKA patients presenting to the emergency department. Serum lactate alone should not be used as an outcome predictor in pediatric DKA.

Impact of balanced versus unbalanced fluid resuscitation on clinical outcomes in critically ill children: protocol for a systematic review and meta-analysis

BACKGROUND

Isotonic crystalloid fluid bolus therapy is used in critically ill children to restore or maintain hemodynamic stability. However, the ideal choice of crystalloid remains to be determined. The most easily available and most frequently used crystalloid is 0.9% saline, an unbalanced crystalloid, that has been associated with hyperchloremic metabolic acidosis and acute kidney injury (AKI). Balanced fluids such as Ringer's lactate (RL) were developed to be closer to the composition of serum. However, they are more expensive and less readily available than 0.9% saline. Few trials have found RL to be associated with more favorable outcomes, but pediatric data is limited and inconsistent. The objective of the present systematic review is to review existing literature to determine the effect of balanced versus unbalanced fluid bolus therapy on metabolic acidosis in critically ill children.

METHODS

Using the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) guidelines, we will conduct a systematic review to retrieve all controlled trials and observational studies comparing balanced and unbalanced resuscitative fluids in critically ill children from age 28 days to 18 years old in any resuscitation settings. Search strategy was developed in collaboration with an experienced clinical research librarian. The primary outcome is the incidence and/or time to resolution of metabolic acidosis. Secondary outcomes included the incidence of hyperchloremia, AKI, duration of renal replacement therapy, vasopressors, mechanical ventilation, total volume of rehydration needed per day, extracorporeal membrane oxygenation, and length of stay and mortality. Study screening, inclusion, data extraction, and assessment of risk of bias will be performed independently by two authors. We intend to perform a meta-analysis with studies that are compatible on the basis of population and outcomes.

DISCUSSION

Isotonic crystalloid fluid bolus therapy is a ubiquitous treatment in resuscitation of critically ill pediatric patients and yet there is no clear recommendation to support the choice of balanced versus unbalanced fluid. The present review will summarize current available data in the literature and assess whether recommendations can be generated regarding the choice of crystalloids or otherwise identify knowledge gaps which will open the door to a large-scale randomized controlled trial (RCT).

Peritoneal dialysis for the rescue in critical refractory metabolic acidosis in diabetic ketoacidosis

Diabetic ketoacidosis is one of the most serious complications of diabetes mellitus. Role of bicarbonate therapy in severe diabetic ketoacidosis is controversial. There are only few case reports of management of refractory diabetic ketoacidosis with renal replacement therapy. Here, we present a case of young male with severe diabetic ketoacidosis, which was refractory to fluid resuscitation, insulin and was managed successfully managed with peritoneal dialysis.

Spectrum of complications of severe DKA in children in pediatric Intensive Care Unit

Objectives:

To describe the spectrum of complications of Diabetic Ketoacidosis (DKA) observed in children admitted with severe DKA.

Methods:

Retrospective review of the medical records of all children admitted with the diagnosis of severe DKA in Pediatric Intensive Care Unit (PICU) of the Aga Khan University Hospital, from January 2010 to December 2015 was done. Data was collected on a structured proforma and descriptive statistics were applied.

Results:

Total 37 children were admitted with complicated DKA (1.9% of total PICU admission with 1.8% in 2010 and 3.4% in 2015). Mean age of study population was 8.1±4.6 years and 70% were females (26/37). Mean Prism III score was 9.4±6, mean GCS on presentation was 11±3.8 and mean lowest pH was 7.00±0.15. Complications observed included hyperchloremia (35.94%), hypokalemia (30.81%), hyponatremia (26.70%), cerebral edema (16.43%), shock (13.35%), acute kidney injury (10.27%), arrhythmias (3.8%), and thrombotic thrombocytopenic purpura (5.4%), while one patient had myocarditis and ARDS each. 13/37 children (35%) needed inotropic support, 11/37 (30%) required mechanical ventilation while only one patient required renal replacement therapy. Two patients (5.4%) died during their PICU stay.

Conclusion:

Hyperchloremia and other electrolyte abnormalities, cerebral edema and AKI are the most common complications of severe DKA.

Admission and treatment factors associated with the duration of acidosis in children with diabetic ketoacidosis

BACKGROUND

Our goal was to determine the factors associated with prolonged acidosis in children with diabetic ketoacidosis.

METHOD

The records of all children (109 admissions, 86 patients) admitted to the pediatric intensive care unit (PICU) during a 3-year period with the diagnosis of diabetic ketoacidosis were analyzed.

RESULTS

The charts were reviewed after institutional review board approval was obtained. Demographic and serial laboratory data, time to correction of acidosis, as well as the first 24-hour chloride load, total fluid administered, fluid balance, and PICU and hospital lengths of stay were recorded. The anion gap (AG = Na - Cl - HCO(3)) and the delta gap (DG = AG - 12 - [24 - HCO(3)]) were calculated. Prolonged acidosis (HCO(3) < 15 mEq/L at 24 hours) was analyzed against various independent factors on admission and during therapy. Low Na (128 vs 133 mEq/L), HCO3 (4.7 vs 9.5 mEq/L), DG (-6.3 vs -2.8 mEq/L), pH (6.97 vs 7.16), PaCO(2) (15 vs 23 mm Hg), and base excess (-26 vs -18) as well as high chloride load (17 vs 11 mEq/kg per 24 hours) were associated with prolonged acidosis (t test, P < 0.05). Stepwise logistic regression eliminated all except base excess and DG in the model. Children with prolonged acidosis had longer PICU (45 vs 34 hours) and hospital stays (5.5 vs 2.5 days) (P < 0.05). The AG was normal in all cases at 24 hours. There were no deaths.

CONCLUSIONS

Nongap acidosis was present in many children with prolonged metabolic acidosis. We suggest that a continuous acetate or bicarbonate therapy via maintenance fluid might be beneficial in this subgroup of patients.