Yung Michael, Letton Georgia, Keeley Steve
Department of Paediatric Critical Care, Women's and Children's Hospital, Adelaide, South Australia, Australia.
J Paediatr Child Health. 2017 Jan;53(1):12-17. doi: 10.1111/jpc.13436.
We 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).
We 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 2 h until intravenous fluids were ceased. The primary outcome was the time for the plasma bicarbonate to reach 15 mmol/L. Secondary outcomes included time to normalise pH (7.3), time to receive subcutaneous (SC) insulin, change in sodium and insulin requirement.
A total of 77 children were enrolled. The groups were similar at baseline. There was no difference in the time to reach a bicarbonate of 15 mmol/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.
HS is an acceptable alternative to NS in DKA and may benefit those with severe DKA.
我们旨在确定在糖尿病酮症酸中毒（DKA）中，与0.9%生理盐水（NS）相比，使用平衡盐溶液哈特曼氏溶液（HS）是否可通过避免高氯性代谢性酸中毒来缩短酸碱状态恢复正常的时间。
我们进行了一项双盲随机对照试验，比较HS与NS作为DKA患儿的初始静脉输液。患者按严重程度（pH < 7.1）以及已知或新发糖尿病进行分层。每2小时测量电解质、静脉血气和血糖，直至停止静脉输液。主要结局是血浆碳酸氢盐达到15 mmol/L的时间。次要结局包括pH恢复正常（7.3）的时间、开始皮下注射（SC）胰岛素的时间、钠的变化以及胰岛素需求量。
共纳入77名儿童。两组在基线时相似。达到碳酸氢盐15 mmol/L的时间无差异：NS组几何均数（标准差）为8.6（2.3）小时，HS组为6.2（4.7）小时，比值为1.4（95%置信区间0.8 - 2.5）；pH恢复正常的时间也无差异：NS组为8.5（2.3）小时，HS组为7.5（1.8）小时，比值为1.1（0.8 - 1.6）。Kaplan-Meier生存估计显示，在严重亚组中这些终点的时间较短：对数秩检验P值分别为0.0277和0.0024。开始SC胰岛素治疗的时间无差异：NS组为15.2（2.4）小时，HS组为14.3（1.6）小时，比值为1.1（0.8 - 1.5）。接受HS治疗的患者每千克体重接受的总液体量显著更少。
在DKA中，HS是NS的可接受替代方案，并可能使重度DKA患者受益。
