Buffered salt solution versus 0.9% sodium chloride as fluid therapy for patients presenting with moderate to severe diabetic ketoacidosis: Study protocol for a Phase-3 cluster-crossover, blinded, randomised, controlled trial.

Hyperglycemic Emergencies in Adults

GIFTAHo; an improvement on GIFTASuP? New NICE guidelines on intravenous fluids.

Objective: To examine the risk and protective factors for severe and recurrent diabetic ketoacidosis (DKA) in a large sample of children in the Southwestern United States. Methods: Retrospective chart review of children age 0-18 years with type 1 diabetes (T1D) seen at a large children's hospital/integrated care delivery system between October 2019 and December 2022. Data from the preceding 2 years were used to predict postdiagnosis DKA in each subsequent year. Logistic regression and recursive feature elimination (RFE) were used to select significant predictors of any DKA, severe DKA, and recurrent DKA. Model performance was evaluated using fivefold cross-validation, with area under the curve in the receiver operating characteristic plot as the performance metric. Results: Records were obtained for 4649 encounters, representing 1850 patients and 846 prior DKA events. Based on RFE, single prior DKA, recurrent prior DKA, and hemoglobin A1c were significant shared predictors for subsequent DKA, severe DKA, and recurrent DKA, and female sex was positively associated with any DKA and recurrent DKA. The model for recurrent DKA also included age between 10 and 14 years as an unshared risk factor, and Hispanic ethnicity and use of an insulin pump (with or without automated insulin delivery) as unshared protective factors. Incidence of severe DKA was highly correlated (r = 0.95) with number of prior DKA events. Black and female patients were more likely to experience multiple recurrent DKA episodes and repeated episodes of severe DKA. Conclusions: Severe and recurrent DKA have both shared and unshared risk factors. Severe DKA may be a singular phenomenon in most cases, although a subset of patients (primarily Black and female) experience repeated severe events, placing them at high risk for adverse health outcomes. Recurrent DKA appears to be more of a chronic issue, although a number of variables emerged as protective factors, suggesting ways in which recurrent DKA might be prevented.

Hofmeister effects in the gelling of silica nanoparticles in mixed salt solutions

Hospital-induced hyponatremia

Managing Diabetic Ketoacidosis in Children

Management of acute hyperglycemic emergencies: focus on diabetic ketoacidosis.

To test the hypothesis that fluid resuscitation in the ED with plasmalyte-148 (PL) compared with 0.9% sodium chloride (SC) would result in a lower proportion of patients with diabetic ketoacidosis (DKA) requiring intensive care unit (ICU) admission. We performed a prespecified nested cohort study at two hospitals within a cluster, crossover, open label, randomised, controlled trial comparing the effects of PL versus SC as fluid therapy for patients who presented to the ED with DKA. All patients presenting within a fixed recruitment period were included. The primary outcome was the proportion of patients admitted to ICU. Eighty-fourpatients were enrolled (SC n=38, PL n=46). The SC group had a lower median pH on admission (SC: 7.09 [interquartile range (IQR) 7.01-7.21], PL: 7.17 [IQR 6.99-7.26]). The median volume of intravenous fluids administered in ED was 2150 mL (IQR 2000-3200 mL; SC) and 2200 mL (IQR 2000-3450; PL); respectively. A higher proportion of patients in the SC group, 19 (50%), was admitted to ICU compared with PL group, 18 (39.1%); however, after adjustment for pH at presentation and diabetes type in a multivariable logistic regression model, the PL group did not have a significantly different rate of ICU admission compared with the SC group (odds ratio for ICU admission 0.73, 95% confidence interval 0.13-3.97, P=0.71). Patients with DKA treated with PL compared with SC in the EDs had similar rates of requiring ICU admission.

To examine factors determining the haemodynamic and metabolic responses to treatment of diabetic ketoacidosis with alkali, groups of anaesthetised and ventilated rats with either diabetic ketoacidosis (mean arterial pH 6.86–6.96, mean arterial blood pressure 63–67 mm Hg) or hypovolaemic shock due to blood withdrawal (mean pHa 7.25–7.27, mean arterial blood pressure 36–41 mmHg) were treated with sodium chloride (‘saline’), sodium bicarbonate or ‘Carbicarb’ (equimolar bicarbonate plus carbonate). In the diabetic ketoacidosis series, treatment with either alkali resulted in deterioration of mean arterial blood pressure and substantial elevation of blood lactate, despite a significant rise in myocardial intracellular pH determined by 31P-magnetic resonance spectroscopy. These effects were accompanied by falling trends in the ratios of myocardial phosphocreatine and ATP to inorganic phosphate. Erythrocyte 2,3-bisphosphoglycerate was virtually absent in animals with diabetic ketoacidosis of this severity and duration. In contrast, in shock due to blood withdrawal, infusion of saline or either alkali was accompanied by a transient elevation of mean arterial blood pressure and no significant change in the already elevated blood lactate; erythrocyte 2,3-bisphosphoglycerate was normal in these animals. The effect of alkalinization in rats with severe diabetic ketoacidosis was consistent with myocardial hypoxia, due to the combination of very low initial erythrocyte 2,3-bisphosphoglycerate, alkali-exacerbated left shift of the haemoglobin-oxygen dissociation curve and artificial ventilation. No evidence was found for any beneficial effect of ‘Carbicarb’ in either series of animals; ‘Carbicarb’ and sodium bicarbonate could be deleterious in metabolic acidosis of more than short duration.

To examine factors determining the haemodynamic and metabolic responses to treatment of diabetic ketoacidosis with alkali, groups of anaesthetised and ventilated rats with either diabetic ketoacidosis (mean arterial pH 6.86-6.96, mean arterial blood pressure 63-67 mm Hg) or hypovolaemic shock due to blood withdrawal (mean pHa 7.25-7.27, mean arterial blood pressure 36-41 mm Hg) were treated with sodium chloride ('saline'), sodium bicarbonate or 'Carbicarb' (equimolar bicarbonate plus carbonate). In the diabetic ketoacidosis series, treatment with either alkali resulted in deterioration of mean arterial blood pressure and substantial elevation of blood lactate, despite a significant rise in myocardial intracellular pH determined by 31P-magnetic resonance spectroscopy. These effects were accompanied by falling trends in the ratios of myocardial phosphocreatine and ATP to inorganic phosphate. Erythrocyte 2,3-bisphosphoglycerate was virtually absent in animals with diabetic ketoacidosis of this severity and duration. In contrast, in shock due to blood withdrawal, infusion of saline or either alkali was accompanied by a transient elevation of mean arterial blood pressure and no significant change in the already elevated blood lactate; erythrocyte 2,3-bisphosphoglycerate was normal in these animals. The effect of alkalinization in rats with severe diabetic ketoacidosis was consistent with myocardial hypoxia, due to the combination of very low initial erythrocyte 2,3-bisphosphoglycerate, alkali-exacerbated left shift of the haemoglobin-oxygen dissociation curve and artificial ventilation. No evidence was found for any beneficial effect of 'Carbicarb' in either series of animals; 'Carbicarb' and sodium bicarbonate could be deleterious in metabolic acidosis of more than short duration.

Specimens of iron and zinc, freshly immersed in salt solutions, commence to suffer attack preferentially at places where the primary, air‐formed oxide‐film is imperfect. Generally, however, on vertical specimens placed in stagnant solutions of sodium (or potassium) chloride (or sulfate), this primary distribution rapidly passes into a secondary distribution, dictated by differential aeration, in which there is one large unattacked area near the water line, with an (anodic) etched region at the bottom and near the cut edges. The state of the original primary film may have a somewhat more lasting effect on the distribution of corrosion in the case of specimens shaken in potassium sulfate solution, since the oxygen is then supplied to all parts of the specimen. Under stagnant conditions, the effect of the state of the primary film is usually transitory, but it may help indirectly to determine the final distribution of attack, since corrosion‐products, descending from a weak spot in the primary film, screen other portions from oxygen and set up anodic attack over the part screened ; also the effect of the cutting stress at the edges is still seen even in an advanced state of corrosion. Thus the factors determining the final distribution of attack are very numerous, but it is impossible to neglect the part played by (a) the state of the primary film, (b) differential aeration and (c) the oxygen‐screening caused where secondary corrosion‐products settle on the surface ; the importance of these three factors is doubtless greater under the conditions of the authors' experiments than under the conditions observed by Dr. Bengough and his colleagues. Ammonium chloride attacks iron and steel more rapidly than sodium chloride and the distribution is different, the corrosion being commonly most rapid at the water line. The action is probably electrochemical, but there are numerous anodic and cathodic areas close together, the lower cell‐resistance explaining the more rapid attack. The fact that the secondary distribution commonly reached in sodium chloride (one large cathodic and one anodic area) is usually not reached in ammonium chloride, appears to be due to the weaker precipitating power of ammonia.

Heparan sulfate from human aorta has been subjected to a physico-chemical analysis in buffers of physiological ionic strength containing either sodium chloride or calcium chloride. A molecular weight of 50,000 was obtained both in sodium and calcium solutions by sedimentation equilibrium and from sedimentation and diffusion coefficients. The values obtained for So20,w in sodium and calcium chloride solutions were 2.28 X 10(-13) and 2.70 X 10(-13) sec, respectively, and the corresponding values for Dl20,w were 2.7 X 10(-7) and 3.1 X 10(-7) cm2/sec, respectively. Diffusion coefficients calculated from data obtained by gel chromatography were in excellent agreement with those determined by conventional techniques. The results indicated that the molecule contracts in the presence of calcium, presumably due to an increased binding of counter-ions with a concomitant decrease in charge density. Circular dichroism spectra above 200 nm, where the substituted amino group contributes to the absorption, gave no indication of a conformational change in the polysaccharide upon transformation from the sodium to the calcium salt. When the polysaccharide was dissolved in a salt solution, physiological both in ionic strength and in sodium to calcium ratio, it sedimented as the sodium salt. The sedimentation coefficient, the diffusion coefficient and the apparent molecular weight all displayed a concentration dependence. This dependence was much less in calcium chloride than in sodium chloride in determinations of molecular weight. Therefore there are advantages in performing molecular weight determinations of glycosaminoglycans in calcium solutions.

Diabetic ketoacidosis (DKA) poses a significant risk to diabetic pediatric patients, warranting effective management strategies to prevent complications. Current DKA management protocols often use normal saline for insulin infusion, which can contribute to hyperchloremia. This study aimed to compare the effects of 2 insulin concentrations (1 unit of regular human insulin per 1 mL vs 1 unit per 10 mL of 0.9% sodium chloride) on the incidence of hyperchloremic metabolic acidosis (HMA). A retrospective observational study was conducted on pediatric patients admitted to a large pediatric hospital, recognized as a leading provider of tertiary pediatric care in the region, from January 2018 to June 2023. The study compared preprotocol (1 unit/10 mL) and postprotocol (1 unit/1 mL) insulin concentrations. Data collected included demographics, DKA severity, electrolytes, intravenous fluid type, total volume, chloride load, and length of hospital stay. The study included 279 DKA admissions, with 140 preprotocol and 139 postprotocol cases. The postprotocol group had a higher incidence of new onset of type 1 diabetes cases. The incidence of HMA was 38% (53 patients) in the postprotocol group, compared with 43% (60 patients) in the preprotocol group, but this difference was not statistically significant (P = .365). Furthermore, the total chloride load per kg in the first 24 hours showed no statistical significance between the pre- and postgroups (mean 11 ± 5 and 11 ± 5, respectively; P = .665). Similarly, length of stay also showed no significant difference between the pre- and postprotocol groups (mean 3 ± 2 vs 4 ± 3, respectively; P = .102). This study examines the comparative effectiveness of 2 insulin concentrations in DKA treatment. Changing insulin concentrations did not influence the incidence of HMA.

To describe the clinical and laboratory changes associated with the use of IV0.9% sodium chloride and a commercially available acetated fluid (CAF) to treat endurance horses requiring emergency medical treatment. Randomized, controlled clinical trial from 2007 to 2010. Emergency treatment centers of the Western States 100-mile (220 km) endurance ride. Twelve horses requiring emergency medical treatment in the form of IVfluids completed the study. Horses were assigned to either the 0.9% sodium chloride group (6 horses) or CAF group (6 horses) and received a total of 20 L of fluid. Clinical, hematologic, and electrolyte data were collected prior to and during fluid therapy. As compared to results prior to fluid therapy, horses treated with 0.9% sodium chloride had a decrease in heart rate (P<0.01), PCV (P<0.001), total plasma protein (TPP) (P<0.001), and the sodium-chloride difference (P<0.05). These horses also had an increase in plasma chloride (P<0.01) and sodium (P<0.01) concentrations. Horses treated with CAF showed a decrease in PCV (P<0.01) and TPP (P<0.001). These findings should aid in the design a larger clinical trial to provide further clarification on the effects of type of fluid therapy on clinical and biochemical parameters in endurance horses. The use of 0.9% sodium chloride may not be ideal for the emergency management of endurance horses as it was associated with an increase in plasma chloride concentration.

Diabetes Mellitus