Controlled trial of Hartmann's solution versus 0.9% saline for diabetic ketoacidosis

AimWe aimed to determine whether using a balanced salt solution, Hartmann's solution (HS), in diabetic ketoacidosis (DKA) shortens the time to normalise acid-base status through the avoidance of hyperchloremic metabolic acidosis compared with 0.9% normal saline (NS). MethodsWe conducted a double-blind, randomised controlled trial comparing HS to NS as the initial intravenous fluid in children with DKA. Patients were stratified by severity (pH<7.1) and known or new diabetes. Electrolytes, venous blood gases and glucose were measured every 2h until intravenous fluids were ceased. The primary outcome was the time for the plasma bicarbonate to reach 15mmol/L. Secondary outcomes included time to normalise pH (7.3), time to receive subcutaneous (SC) insulin, change in sodium and insulin requirement. ResultsA total of 77 children were enrolled. The groups were similar at baseline. There was no difference in the time to reach a bicarbonate of 15mmol/L: geometric mean (SD) 8.6 (2.3) h for NS versus 6.2 (4.7) h for HS, ratio 1.4 (95% confidence interval 0.8-2.5), and no difference in time to normalise pH: NS 8.5 (2.3) h versus HS group 7.5 (1.8) h, ratio 1.1 (0.8-1.6). Kaplan-Meier survival estimates showed shorter times for these end-points in the severe subgroup: log-rank test P=0.0277 and 0.0024, respectively. There was no difference in time to SC insulin, NS: 15.2 (2.4) h versus HS 14.3 (1.6) h, ratio 1.1 (0.8-1.5). Patients treated with HS received significantly less total fluids/kg. Conclusions HS is an acceptable alternative to NS in DKA and may benefit those with severe DKA.