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a recent study shows balanced fluids tend to resolve DKA faster than saline. no shock here - giving acidic fluid to an acidotic patient is subawesome. but I want to deeper here to explore specific reasons *not* to give saline...
(full article: https://bit.ly/3pJ0Q5d )
(full article: https://bit.ly/3pJ0Q5d )
reason #1: bolusing NS can cause pH shifts that cause K to shift out of cells, exacerbating hyperkalemia. DKA patients tend to be hyperkalemic at baseline, so pushing up their K more could be dangerous. have seen this once, it's rare, let's keep moving..
https://bit.ly/3nO9rlF
https://bit.ly/3nO9rlF
reason #2: bolusing NS may reduce pH, which could destabilize a patient with profoundly low baseline pH (e.g. your rare patient with unmeasurably low bicarb and pH<<7). there is a pH cliff and it does has an edge. this is exceedingly rare, probably even moreso than #1...
reason #3: main reason balanced crystalloids are superior: they limit the development of NAGMA that may lead to a lingering acidosis (even after the ketoacidosis has resolved). ongoing NAGMA isn't life-threatening, but it delays weaning off insulin gtt. https://emcrit.org/pulmcrit/bicarbonate-dka/
trials will never be able to prove #1 or #2 (far too rare!), but may be able to prove #3. but how much evidence do you need to support such basic physiology? we stopped using saline for DKA resus ~2014 and this has made our lives easier (
anecdotal!) https://emcrit.org/pulmcrit/four-dka-pearls/
anecdotal!) https://emcrit.org/pulmcrit/four-dka-pearls/
