Rozinadya Tamzil1, Normalinda Yaacob1*, Norhayati Mohd Noor2, Kamarul Aryffin Baharuddin1

1Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
2Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia

Keywords: Balanced electrolyte solutions, diabetes ketoacidosis, meta‑analysis, normal saline, systematic review


The first line treatment of diabetes ketoacidosis (DKA) involves fluid resuscitation with normal saline infusion to correct hypovolemia. Hyperchloremic metabolic acidosis from aggressive normal saline administration was associated with worse clinical outcomes in managing DKA. Other choices for normal saline include balanced electrolyte solutions (BESs). This study aimed to compare the clinical effects between BESs and normal saline in managing DKA. This study was a systematic review of probing articles published from inception to October 2021 in Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online, Google Scholar, and Scopus. Eight randomized controlled trials with a total of 595 individuals were included. The data were analyzed at 95% confidence level using random effects models. For the primary outcomes, there was no difference in the duration of DKA resolution. (Mean difference [MD] −4.73, 95% confidence interval [CI] −2.72–4.92; I2 = 92%; P = 0.180). However, there was a significantly lower postresuscitation chloride concentration in the BES (MD 2.96 95% CI − 4.86 to − 1.06; I2 = 59%; P = 0.002). For the secondary outcomes, there was a significant reduction in duration for normalization of bicarbonate in the BES group (MD 3.11 95% CI − 3.98 2.23; I2 = 5%; P = 0.0004). There were no significant differences between groups in duration for recovery of pH, intensive unit admission, and adverse events (mortality and acute renal failure). Resuscitation with BES was associated with decreased chloride and increased bicarbonate values in DKA patients. It suggests that BES prevents DKA patients from hyperchloremic metabolic acidosis.

How to cite this article: Tamzil R, Yaacob N, Noor NM, Baharuddin KA. Comparing the clinical effects of balanced electrolyte solutions versus normal saline in managing diabetic ketoacidosis: A systematic review and meta-analyses. Turk J Emerg Med 2023;23:131-8.

Author Contributions

• Designing the review: Rozinadya Tamzil (RT). Normalinda Yaacob (NY), Norhayati Mohd Noor (NMN). Kamaru Aryffin Baharuddin (KAB)
• Co ordinating the review: RT, NY, NMN
• Literature search: RT, NY, NMN, KAB
• Quality assessment: RT, NY, KAB
• Entering data into RevMan: RT
• Data analysis: RT, NY, NMN, KAB
• Data interpretation: RT, NY, NMN. KAB
• Writing the review: RT, NY, NMN, KAB.

Conflict of Interest

None Declared.

Financial Disclosure



The School of Medical Sciences, Universiti Sains Malaysia.