Non-invasive haemodynamic monitoring to individualise fluid resuscitation in adult diabetic ketoacidosis: A randomized controlled pilot trial

Table 9 Evidence landscape for fluid resuscitation in diabetic ketoacidosis

Evidence domain	Direction	Certainty	Clinical maturity	Core interpretation
Guideline-based fluid resuscitation	↑	Moderate	Established care	Fluid resuscitation remains foundational, but most protocols rely on fixed formulas and static clinical assessment
Fluid composition: Balanced crystalloids vs normal saline	↗	Low-moderate	Selective clinical use	Balanced fluids may improve acid-base or chloride profiles, but evidence remains heterogeneous
Fluid rate and volume strategies	?/↗	Low-moderate	Contextual evidence	Paediatric evidence predominates; optimal adult-specific rates and volumes remain uncertain
Rehydration timing and complications	?	Low	Contextual/risk evidence	Excessive or poorly tailored fluid strategies are associated with neurological complications, AKI, or prolonged hospitalisation, but causal inference is limited
Protocol/order-set implementation	↗	Low-moderate	Implementation evidence	Standardised protocols may improve adherence and DKA resolution but may introduce trade-offs such as hypoglycaemia
Adult DKA evidence-based	?	Low	Evidence gap	Adults remain underrepresented despite high clinical burden and comorbidity-related fluid-overload risk
Dynamic haemodynamic monitoring	↗	Low	Experimental clinical approach	No previous included study used non-invasive haemodynamic or stroke-volume-guided protocols; the present pilot trial provides proof-of-concept evidence
High-risk adults, older patients, and those with cardiac/renal comorbidity	?	Very low	Hypothesis-generating	These populations may benefit most from individualised monitoring, but direct evidence is sparse
Resource-limited emergency settings	↗	Low	Translational promise	Portable, non-invasive monitoring may be scalable when invasive monitoring is unavailable, but evidence of its implementation is needed

This table summarises the direction, certainty, and clinical maturity of evidence across primary domains identified in the embedded narrative synthesis of studies on diabetic ketoacidosis (DKA) rehydration. Evidence was organised into domains concerning rehydration timing and complications, fluid type, fluid volume and rate, protocol implementation, adult evidence gaps, and dynamic haemodynamic monitoring. Direction symbols indicate whether the available evidence supports established or clinically relevant practice, suggests promising but preliminary findings, or remains uncertain or indirect. The clinical translation continuum distinguishes established guideline-based care, selective clinical use, contextual or implementation evidence, experimental clinical approaches, and evidence gaps requiring future trials. Overall, the evidence supports the central role of fluid resuscitation in DKA, but most existing studies rely on fixed protocols, fluid-composition comparisons, or retrospective data on implementation. Adult DKA populations are underrepresented, and no previous study in the included evidence base used non-invasive haemodynamic monitoring or stroke-volume-guided fluid resuscitation. The present ultrasonic cardiac output monitor-guided pilot trial therefore occupies the experimental clinical approach stage and provides proof-of-concept evidence for a physiology-guided strategy. Certainty categories are narrative and reflect study design, population relevance, consistency, and directness. “↑”: Established or clinically relevant evidence; “↗”: Promising but preliminary evidence; “?”: Uncertain, indirect, or heterogeneous evidence; AKI: Acute kidney injury; DKA: Diabetic ketoacidosis.