From the Research
Lactated Ringer's is preferred over normal saline in the treatment of diabetic ketoacidosis (DKA) due to its ability to resolve high anion gap metabolic acidosis faster and improve patient outcomes, as demonstrated in recent studies 1, 2, 3, 4.
Key Points to Consider
- The most recent and highest quality studies, including a systematic review and meta-analysis 3 and a subgroup analysis of cluster randomized clinical trials 4, suggest that balanced crystalloids like lactated Ringer's may be superior to normal saline in the treatment of DKA.
- Lactated Ringer's has been associated with faster resolution of high anion gap metabolic acidosis and improved patient outcomes, including shorter time to DKA resolution and reduced duration of insulin infusion 1, 2.
- Normal saline, on the other hand, can cause hyperchloremic metabolic acidosis and may lead to delayed resolution of DKA 5, 3.
- The American Diabetes Association recommends normal saline as the initial fluid of choice, but recent evidence suggests that lactated Ringer's may be a better alternative 1, 2, 3, 4.
Clinical Implications
- When treating DKA, the initial fluid of choice should be lactated Ringer's, administered at a rate of 15-20 mL/kg/hour for the first hour, followed by 4-14 mL/kg/hour thereafter, depending on the patient's hydration status and clinical response.
- Lactated Ringer's can help correct the sodium deficit and address the profound dehydration that characterizes DKA, while also resolving high anion gap metabolic acidosis faster than normal saline.
- Once the patient's blood glucose falls below 200-250 mg/dL, the IV fluid should be changed to include dextrose (typically D5 lactated Ringer's) to prevent hypoglycemia while continuing insulin therapy to clear ketones.