???? REBEL Rundown ????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.

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???? 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 Question

Does the fluid you choose affect how quickly acidosis resolves in DKA? 

IV Fluid Composition

???? 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.

Post Peer Reviewed By: Marco Propersi (Twitter/X: @Marco_propersi), and Kim Bambach, MD

Show Notes By: Mark Ramzy, DO

Authors Mark Ramzy, DO Co-Editor-in-Chief RWJBH / Rutgers Health, Newark, NJ Frank Lodeserto Associate Editor Cape Fear Valley Medical Center, Fayetteville NC ???? Your Deep-Dive Starts Here REBEL Core Cast – DKA: Beyond the Basics Part 2 – SCOPE DKA-Trial

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is the blogs audio version. The podcast typically starts by setting a clinical stage with a pertinent clinical question, followed by a discussion of the paper with pertinent results, strengths, limitations, and further discussion. Finally, we end every podcast with clinical take home points from the papers being reviewed. If there are papers you think we should evaluate, email them to srrezaie@gmail.com.

REBEL EM stands for Rational Evidence Based Evaluation of Literature in Emergency Medicine.  We cover a myriad of topics, primarily focusing on evidence-based clinical topics.

At its core, evidence-based medicine (EBM) incorporates clinical judgment, relevant scientific evidence, and patient values/preferences. Research and scientific evidence help inform care but should not dictate care of patients.

With the constant influx of new published research, it makes it difficult to stay current with the latest and greatest. REBEL EM was created October 2013 in an effort to cut down knowledge translation of research to clinical application (Bench to Bedside), using a structured critical appraisal method of evaluation.

REBEL Core Cast – DKA: Beyond the Basics Part 2 – SCOPE DKA-Trial Mark Ramzy October 21, 2025 No Comments

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.

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