REBEL Core Cast – DKA: Beyond the Basics Part 2 – SCOPE DKA-Trial

Oct 21, 2025

Fluid choice is crucial in managing severe diabetic ketoacidosis. The SCOPE-DKA trial shows that Plasma-Lyte corrects acidosis faster than normal saline, which may worsen acidosis due to its chloride content. The trial's design strengthens its findings, but it highlights the need for more research comparing different fluid types. Important metrics like base excess and strong ion difference are often overlooked when assessing acid-base status. The podcast discusses ethical considerations and the impact of protocols on patient care and nursing workload.

Ask episode

AI Snips

Chapters

Transcript

Episode notes

INSIGHT

Not All DKA Requires ICU

DKA management follows a triad: fluids, electrolytes, and insulin, but not all DKA needs ICU-level care.
Mild to moderate DKA can be managed outside ICU with protocolized approaches like SQUID when appropriate.

ANECDOTE

SQUID Trial Implementation Story

Frank described implementing the SQUID protocol in a busy urban ED using subcutaneous lispro every four hours plus a basal glargine.
They compared this to traditional insulin drips in patients with mild to moderate DKA and collected outcomes.

INSIGHT

Operational Benefits Of SQUID

The SQUID group had a roughly three-hour shorter ED length of stay and far fewer ICU admissions than the traditional group.
Safety outcomes like hypoglycemia rates were similar between groups.

Get the Snipd Podcast app to discover more snips from this episode

Get the app

🔑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.

Click here for Direct Download of the Podcast.

📝 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

It seems we can't find what you're looking for.

REBEL Cast

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.