We report a case of diabetic ketoacidosis (DKA) with normal
anion-gap secondary to hyperchloremia at admission. Normal
saline may not be the ideal fluid for resuscitation in this
setting because saline rehydration can induce and/or sustain
hyperchloremic acidosis.
A 7-year old child was admitted for
evaluation of abdominal pain of 3-week duration. Two days
after admission, he developed increasing abdominal pain and
tachypnea with normal chest findings. Random blood glucose
was ‘high’ on glucometer. Arterial pH (6.9) and urine ketone
bodies (3+) suggested DKA. After 20 mL/kg normal saline (NS)
bolus, standard DKA protocol (assuming 10% dehydration) was
initiated. Serial measurements of acid-base and electrolyte
status are shown in Table I. Normal anion-gap
acidosis and persistent base deficit were noted during the
stay. The possibility of underlying distal renal tubular
acidosis [1] was ruled out based on renal bicarbonate
excretion and urinary anion-gap.
TABLE I Electrolyte and Acid–base Parameters Observed During the PICU Stay
|
Time (hours) |
Parameter |
0 |
4 |
10 |
16 |
28 |
38 |
48 |
65 |
Na+ (mEq/L) |
154 |
150 |
144 |
145 |
138 |
132 |
135 |
136 |
K+ (mEq/L) |
1.5 |
2.0 |
2.5 |
2.8 |
3.0 |
3.9 |
4.2 |
4.4 |
Cl– (mEq/L) |
142 |
135 |
128 |
123 |
118 |
108 |
112 |
112 |
pH |
6.9 |
7.06 |
7.10 |
7.26 |
7.30 |
7.35 |
7.39 |
7.40 |
pCO2 (mm Hg)
|
14.2 |
13.5 |
14.5 |
30.7 |
25.4 |
29.8 |
27.8 |
25.4 |
HCO3 (mEq/L) |
4.2 |
4.4 |
5.0 |
13.5 |
12.1 |
16.6 |
16.5 |
15.5 |
SBE (mEq/L) |
–25 |
–24.8 |
–22.3 |
–12.3 |
–12.4 |
–7.4 |
–6.7 |
–7.26 |
Anion gap (mEq/L) |
9.3 |
12.6 |
13.5 |
11.3 |
10.9 |
11.3 |
10.7 |
12.9 |
“AG/”HCO3 |
0.15 |
0.07 |
0.03 |
0.08 |
0.11 |
0.12 |
0.23 |
0.13 |
SIG (mEq/L) |
7.8 |
– |
– |
– |
16.3 |
– |
– |
– |
Serum albumin (g/dL) |
3.0 |
– |
– |
– |
3.1 |
– |
– |
– |
Creatinine (mg/dL) |
0.2 |
– |
– |
– |
0.5 |
– |
0.2 |
– |
Urine Ketone* |
3+ |
2+ |
1+ |
1+ |
– |
– |
– |
– |
Urine (mL/kg/hr) |
– |
7.8 |
7.6 |
6.8 |
5.2 |
4.0 |
3.2 |
3.0 |
Fall in blood glucose (mg/dL/hr) |
– |
– |
32 |
50 |
56 |
80 |
– |
– |
AG- anion gap; Cl–
chloride; HCO3- bicarbonate; K+
potassium; Na+ sodium; SBE standard base
excess; SIG strong ion gap; *dipstick method; Normal
anion gap in our laboratory is 12. Serum lactate at
admission was 3.2 mmol/L. |
Hyperchloremic metabolic acidosis (HMA)
in DKA, especially during recovery, have been reported [2]
The mechanism of early HMA in our case could be gradual
development of ketoacidosis and persistent urinary loss of
ketoanions. A normal corrected sodium level in our patient
suggested adequate oral water intake before admission to
intensive care unit. HMA in children and adults during DKA
management is associated with slow recovery from acidosis
[3]. In a retrospective study [4], prolonged intensive care
unit and hospital stay were observed in those with non-gap
acidosis (secondary to hyperchloremia).
Use of normal saline as a rehydration
fluid is known to cause dilutional-hyperchloremic acidosis.
A recent trial [5] showed extended insulin requirement
and hospital stay in those who received only NS as
post-bolus rehydration fluid or those who received NS but
were switched to during recovery when compared with children
who received only N/2 saline. Earlier resolution of acidosis
was observed when Plasmalyte (containing sodium 140
mEq/L, potassium 5 mEq/L, chloride 98 mEq/L, magnesium 3 mEq/L,
acetate 27 mEq/L, gluconate 23 mEq/L; osmolality: 294 mOsm/L)
was used [6] instead of NS in the initial 12-hours of
management of DKA. An adult trial comparing NS with Ringer’s
lactate (RL) failed to show significant difference in
time-to-resolution of DKA [7]. The only randomized trial
comparing NS with balanced electrolyte solution (BES) for
fluid resuscitation in children with DKA revealed that BES
consistently prevented HMA [8]. The benefit of BES is
attributable to a serum-like pH (7.4) and lower (98mEq/L)
chloride content when compared with NS and RL. However,
theoretical risk of hyperkalemia exists with use of RL [9].
In India, the lack of universal availability of BES/Plasmalyte
and N/2 saline limits their use.
Though saline rehydration is the current
standard of care, the debate concerning the ideal
resuscitation fluid in DKA continues [10]. Normal saline,
being neither ‘normal’ nor physiological (pH 5.5 with a high
chloride content) can sustain hyperchloremia as shown in
this case. Randomized trials comparing balanced fluids (like
RL) with NS for rehydration in DKA are needed to determine
the choice of fluid in DKA. Pediatricians must be cognizant
of hyperchloremic acidosis in DKA.
1. Dymot JA, McKay GA. Type 1 (distal)
renal tubular acidosis in a patient with Type 1 diabetes
mellitus—not all cases of metabolic acidosis in Type 1
diabetes mellitus are due to diabetic ketoacidosis. Diabet
Med. 2008;25:114-5.
2. Oh MS, Banerji MA, Carroll HJ. The
mechanism of hyperchloremic acidosis during the recovery
phase of diabetic ketoacidosis. Diabetes.
1981;30:310-3.
3. Mrozik LT, Yung M. Hyperchloraemic
metabolic acidosis slows recovery in children with diabetic
ketoacidosis: a retrospective audit Aust Crit Care.
2009;22:172-7.
4. Kimura D, Raszynski A, Totapally BR.
Admission, and treatment factors associated with the
duration of acidosis in children with diabetic ketoacidosis.
Pediatr Emerg Care. 2012;28:1302-6.
5. Basnet S, Venepalli PK, Andoh J,
Verhulst S, Koirala J. Effect of normal saline, and half
normal saline on serum electrolytes during recovery phase of
diabetic ketoacidosis. J Intensive Care Med. 2012 Nov 19. [Epub
ahead of print] doi: 10.1177/0885066612467149
6. Chua HR, Venkatesh B, Stachowski E,
Schneider AG, Perkins K, Ladanyi S, et al. Plasma-yte
148 vs 0.9% saline for fluid resuscitation in diabetic
ketoacidosis J Crit Care. 2012;27:138-45.
7. Van Zyl DG, Rheeder P, Delport E.
Fluid management in diabetic-acidosis– Ringer’s lactate
versus normal saline: a randomized controlled trial. QJM.
2012;105:337-43.
8. Mahler SA, Conrad SA, Wang H, Arnold
TC. Resuscitation with balanced electrolyte solution
prevents hyperchloremic metabolic acidosis in patients with
diabetic ketoacidosis. Am J Emerg Med. 2011;29:670-4.
9. Dhatariya K. Diabetic ketoacidosis.
BMJ. 2007;334:1284-5.
10. Olivieri L, Chasm R. Diabetic ketoacidosis in the
pediatric emergency department. Emerg Med Clin N Am.
2013;31:755-73.