Balanced crystalloids versus normal saline for fluid therapy in pediatrics diabetic ketoacidosis: a systematic review

Vollständiger Abstract

Worum geht es in dieser Arbeit?

Fluid therapy is a cornerstone of management in paediatric diabetic ketoacidosis (DKA). Although normal saline has traditionally been the preferred resuscitation fluid, concerns regarding hyperchloremic metabolic acidosis have led to increasing interest in balanced crystalloids such as Ringer’s lactate and Plasma-lyte. However, evidence regarding their efficacy and safety in children with DKA remains limited and has not been comprehensively synthesized. A systematic review of the literature was conducted to evaluate balanced crystalloids versus normal saline for fluid therapy in paediatric DKA. PubMed/MEDLINE, Embase, Scopus, Web of Science, and the Cochrane central register of controlled trials were searched from database inception to March 2026. Randomized controlled trials and comparative observational studies involving children and adolescents with DKA were included. Outcomes of interest included time to DKA resolution, resolution of acidosis, incidence of hyperchloremia, serum bicarbonate recovery, incidence of acute kidney injury (AKI), cerebral edema and duration hospital stay. Four comparative studies involving 49,920 paediatric patients were included in this systematic review. Out of these studies three were randomized controlled trials and one was retrospective observational study. Balanced crystalloids were consistently found to be associated with lower chloride accumulation, decreased incidence of hyperchloremia and improved bicarbonate recovery as compared to cases treated by normal saline. DKA and acidosis resolution demonstrated a trend toward earlier metabolic recovery with balanced crystalloids. No clear difference was observed in the incidence of AKI, intensive care unit stay, or hospital stay between treatment groups. One large observational study reported a lower rate of cerebral edema among children receiving Ringer’s lactate compared with normal saline. Balanced crystalloids appear to be safe and effective alternatives to normal saline for fluid therapy in paediatric DKA. They are associated with favorable clinical and biochemical outcomes specially with respect to chloride homeostasis and bicarbonate recovery. Larger multicenter randomized controlled trials are required to confirm these findings and determine their impact on clinically important outcomes.