🗝️Key Points

• 💧 Fluid Choice Matters: Plasma-Lyte, a balanced crystalloid, corrected acidosis faster than normal saline in severe DKA patients, with no increase in adverse events.
• 🧪 Chloride Load Concerns: Normal saline's high chloride content can worsen acidosis, potentially slowing bicarb recovery even after the anion gap closes.
• 🔬 Study Design Strengths: The SCOPE-DKA trial was a cluster crossover, open-label RCT, protocolizing all variables except fluid type, enhancing the reliability of its findings.
• 🧮 Base Excess & Strong Ion Difference: Base excess/deficit and strong ion difference are valuable but underutilized tools for assessing acid-base status—don't rely solely on pH or bicarb.
• ⚠️ Limitations & Next Steps: The study did not include lactated Ringer's, and fluid rates were left to clinical discretion. More research, including three-arm trials, is needed for definitive guidance.

📝 Introduction

Managing diabetic ketoacidosis (DKA) requires careful consideration of fluid therapy, especially in severe cases. In part two of our REBEL Cast DKA series, we shifted from insulin strategies to fluid choice in severe DKA, diving into the SCOPE-DKA trial—a cluster, crossover, open-label RCT from Australia. While normal saline (NS) is commonly used, concerns about its high chloride content and impact on acidosis have sparked growing interest in balanced solutions like Plasma-Lyte.

🚨 Clinical Bottom Line

Plasma-Lyte showed a modest but meaningful benefit over normal saline in resolving metabolic acidosis in patients with severe DKA. Though safety profiles were similar, the more balanced electrolyte composition of Plasma-Lyte helped normalize acid-base status slightly faster—without worsening ketosis. While this won't revolutionize care overnight, it's one more step toward physiologic resuscitation in DKA. Understanding fluid composition and its impact on acid-base balance is crucial for optimal patient care.