A typical approach includes utilizing a broad-spectrum antibiotic (frequently a beta-lactam such as cefepime or piperacillin-tazobactam) plus an anti-MRSA agent (typically vancomycin).Įarly in the patient’s hospital stay they may have limited IV access, so the question often arises as to which antibiotic to give first, the broad-spectrum antimicrobial or the anti-MRSA agent. Critically-ill patients and those with a suspected infection at risk for severe illness are generally administered two (or more) empiric antibiotics in the emergency department (ED) which cover a wide range of potential pathogens. Accessed January 3, 2022.Įarly antibiotics are recommended for treatment of many infections, including patients with sepsis or septic shock. SCOPE-DKA: Normal Saline vs Plasmalyte in Severe DKA. Sodium chloride or Plasmalyte-148 evaluation in severe diabetic ketoacidosis (Scope-dka): a cluster, crossover, randomized, controlled trial. Ramanan M, Attokaran A, Murray L, et al.Clinical effects of balanced crystalloids vs saline in adults with diabetic ketoacidosis: a subgroup analysis of cluster randomized clinical trials. 0.9% saline versus Plasma-Lyte as initial fluid in children with diabetic ketoacidosis (SPinK trial): a double-blind randomized controlled trial. Williams V, Jayashree M, Nallasamy K, Dayal D, Rawat A.Resuscitation with balanced electrolyte solution prevents hyperchloremic metabolic acidosis in patients with diabetic ketoacidosis. Mahler SA, Conrad SA, Wang H, Arnold TC.The Management of Diabetic Ketoacidosis in Adults. Joint British Diabetes Societies Inpatient Care Group.Canadian Diabetes Association Clinical Practice Guidelines Expert Committee, Goguen J, Gilbert J.Hyperglycemic crises in adult patients with diabetes. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN.Diabetic ketoacidosis in infants, children, and adolescents: A consensus statement from the American Diabetes Association. Wolfsdorf J, Glaser N, Sperling MA, American Diabetes Association.Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site. Want to learn more about EM Pharmacology? However, for subsequent liters, a balance crystalloid (e.g., PlasmaLyte-148, or lactated Ringer’s) should be used instead of sodium chloride 0.9%. Generally, the composition of the initial liter is less important than prompt administration.Though these findings need confirmation in a large, Phase 3 trial. PlasmaLyte-148 (PlasemaLyte A) may lead to faster resolution of metabolic acidosis than sodium chloride 0.9%.The available data suggests that balanced fluids are beneficial in mild, moderate, and severe DKA. To further explore the nuances, strengths, and weaknesses of this study, please read the REBEL EM review by Dr. The study authors concluded that PlasmaLyte-148 may lead to faster resolution of metabolic acidosis in patients with DKA without an increase in ketosis, in line with findings from previous studies, but these results need to be confirmed in a larger, Phase 3 trial. However, by 48-hours, both groups had similar rates of DKA resolution (96% vs 86%, p=0.111). At 24-hours, more patients in the PlasmaLyte group had resolution of DKA (defined as base excess ≥ -3 mEq/L) as compared to the sodium chloride group (69% vs 36%, p=0.002). During the first 48 hours of treatment, patients received a average of ~6.5 L of fluid. EvidenceĪ phase-2 study published in 2021, SCOPE-DKA, randomized 93 patients with severe DKA (median venous pH 7.0) to receive PlasmaLyte-148 ( PlasmaLyte-A) or sodium chloride 0.9%. Josh Farkas provides further review of this topic in 3 excellent and detailed EMCrit posts. Randomized trials, in adult and pediatric patients, demonstrate faster resolution of DKA when using balanced solutions ( e.g., PlasmaLyte-A, lactated Ringer’s) compared to sodium chloride. Many guidelines and treatment algorithms for diabetic ketoacidosis (DKA) recommend sodium chloride 0.9% as the replacement fluid of choice, though alternative fluids may be a better option.
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