Correlation between the Serum Chloride Levels and the Anion Gap Values in Initial Fluid Resuscitation with Normal Saline in Patients with Diabetic Ketoacidosis at RSUD dr. Saiful Anwar Malang

Abstract

Introduction : Diabetic ketoacidosis (DKA) is characterized by uncontrolled hyperglycemia, ketonemia, and metabolic acidosis. Osmotic diuresis as a result of uncontrolled hyperglycemia causes intracellular dehydration and electrolyte deficits. Excessive production of ketone bodies in the blood instigates high anion gap metabolic acidosis (HAGMA). Fluid resuscitation with normal saline is the initial management of DKA frequently performed at Saiful Anwar Hospital because this infusion fluid is rich in chloride content. Hyperchloremia contributes to the occurrence of normal anion gap metabolic acidosis (NAGMA) after rehydration with large amounts of normal saline because an increase in the chloride levels is not counterbalanced by an increase in the bicarbonate ion concentrations in plasma. Although the anion gap values decrease, acidosis still occurs. A normal anion gap is a recovery sign of DKA. Therefore, research is needed to examine the description and correlation of changes in the serum chloride levels and changes in the anion gap values before and after fluid resuscitation with normal saline. Method : Analytic observational research with cross-sectional approach. A sample of 15 people was collected from July to December 2018 in the emergency department (ED) of Saiful Anwar Hospital. Results : Significant changes were found in the serum chloride levels (p = <0.001) and in the anion gap values (p = 0.002) before and after fluid resuscitation with normal saline in patients with DKA. Correlation test results showed a significant relationship between changes in the serum chloride levels and changes in the anion gap values before and after fluid resuscitation with normal saline in patients with DKA (p = <0.001, r = -0.848). Conclusions : Significant changes were found in the serum chloride levels and in the anion gap values before and after fluid resuscitation with normal saline in patients with DKA. The serum chloride levels tended to increase, whereas the anion gap values tended to decrease. Correlation test showed that there was a significant relationship between changes in the serum chloride levels and changes in the anion gap values. The relationship was strong, meaning that the more increasing changes in the serum chloride levels were, the more decreasing changes in the anion gap values would be or vice versa. Keywords : The chloride level, the anion gap, normal saline, 0.9% NaCl, diabetic ketoacidosis, changes in chloride, changes in the anion gap, correlation between chloride and the anion gap. DOI : 10.7176/JHMN/66-10 Publication date :September 30 th 2019