Date of Award

Summer 8-11-2012

Degree Type

Capstone Project

Degree Name

Master of Science in Physician Assistant Studies

First Advisor

Mark Pedemonte, MD

Second Advisor

Annjanette Sommers PA-C, MS

Abstract

BACKGROUND: Patients presenting with diabetic ketoacidosis (DKA) are hypovolemic, hyperglycemic, and acidotic. First line therapy is administration of resuscitation crystalloid fluids to increase systemic pressure for maintenance of tissue perfusion. Volume repletion can be measured by monitoring several physiological indicators including mean arterial pressure (MAP) and urine output (UO), where an increase of both indicate an improvement in volume status. The crystalloid fluid recommended by the American Diabetes Association (ADA) is normal saline (NS) because it has a track record of being a safe option. However, administration of NS can induce hyperchloremic metabolic acidosis (HMA) in many patients receiving it for rapid and large volume fluid replacement in a spectrum of circumstances and in most who receive it for DKA. An alternate crystalloid, Plasma-Lyte, is a balanced electrolyte solution (BES) with composition similarities to plasma, therefore it has less potential to cause biochemical changes in electrolytes, such as hyperchloremic acidosis. In this study evidence for use of a Plasma-Lyte (PL) versus NS was evaluated to determine if Plasma-Lyte is a better option for fluid resuscitation of DKA.

METHODS: A thorough search was conducted in three separate databases, Medscape, CINAHL, and Web of Science. Search terms included: diabetic ketoacidosis, Plasma-Lyte, normal saline, hyperchloremic acidosis, and fluid resuscitation. Eligibility criteria were limited to adult DKA patients receiving NS or PL fluid therapy. Data quality was assessed using the GRADE system.

RESULTS: Two studies were determined eligible. Results were significant for hyperchloremia in groups receiving NS in both studies. In one study, Chua et al showed significant increases (p = < 0.01) in bicarbonate in the PL group at two intervals between 4 and 12 hours after fluid therapy initiation. Mahler et al found only a relative difference (p < .02) in bicarbonate between groups. Chua et al also found the mean arterial blood pressure at 2-4 hours and urine output at 4-6 to be higher in Plasma-Lyte therapy compared with normal saline.

CONCLUSION: DKA patients treated with Plasma-Lyte had lower serum chloride concentrations and higher serum bicarbonate concentrations compared with NS. Inference can also be made for some benefit in time of recovery with more rapidly improved MAP and UO in DKA with a PL versus NS.

KEYWORDS: Diabetic Ketoacidosis; PlasmaLyte; Balanced Electrolyte Solution; Normal Saline; Hyperchloremic Metabolic Acidosis; Fluid Resuscitation

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