Recent studies have shown improved renal outcomes in adult patients with sepsis receiving balanced solutions instead of "normal" saline. For years, it has been known that 0.9% saline (colloquially referred to as "abnormal saline") can cause a hyperchloremic (non-anion gap) metabolic acidosis. The SMART and SALT-ED studies showed worsened acute kidney injury and greater dialysis in patients with septic shock treated with 0.9% saline compared with a balanced solution with a significantly lower chloride concentration. The findings led to increased use of balanced solutions in patients with sepsis and suggested that those with other clinical conditions may benefit from this approach — specifically, patients with diabetic ketoacidosis (DKA). In the case of DKA, we need a solution that can restore euvolemia and mitigate the underlying acidosis.
In 2017, an Australian group of researchers compared Hartmann solution (lactated Ringer) vs 0.9% saline in a small number of children with DKA. There was no difference between the two treatments in the time to resolution of the acidosis, as measured by a serum bicarbonate level > 14 mEq/L; however, the researchers did not evaluate renal outcomes.
In the SPinK trialpediatric patients with DKA were randomly assigned to receive Plasma-Lyte A (balanced solution) or 0.9% saline. Any patient presenting in hypovolemic shock was first resuscitated with a bolus of the fluid type they were assigned. Once shock resolved, the patients were treated until their total fluid deficit was corrected or their glucose reached ≤ 250 mg/dL.
