Diabetic ketoacidosis (DKA) is a life-threatening metabolic complication of diabetes mellitus requiring aggressive intravenous fluid resuscitation. Although the recommended fluid has always been 0.9% normal saline (NS), its supraphysiological chloride load may induce hyperchloremic metabolic acidosis, potentially complicating DKA management. Balanced crystalloids (BCs), with electrolyte compositions more closely approximating human plasma, have emerged as potentially advantageous alternatives. This systematic review compares the clinical outcomes of NS with BCs for fluid resuscitation in patients with DKA. A comprehensive literature search was conducted in PubMed/MEDLINE, Scopus, Embase, and CENTRAL (2021-2026) following PRISMA guidelines. Studies that directly compared 0.9% NS with BCs (such as lactated Ringer's (LR) solution, Plasma-Lyte 148, Isolyte, Sterofundin, or other balanced electrolyte solutions (BES)) for DKA resuscitation were included. The outcomes of interest included time to DKA resolution, electrolyte profiles, insulin infusion duration, length of stay (LOS), acute kidney injury (AKI), and mortality. The risk of bias (ROB) was assessed using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) (for non-randomized studies) and RoB 2 (for randomized controlled trials (RCTs)). Nine studies, four RCTs and five non-randomized studies, comprising 1416 patients, met the inclusion criteria. BCs consistently reduced hyperchloremia and improved bicarbonate profiles compared with NS. Insulin infusion duration was significantly shorter with BCs in two studies. Length-of-stay outcomes were mixed, with some studies showing shorter hospital or ICU stays with BCs. No significant differences in AKI incidence or mortality were observed between groups. The ROB ranged from moderate to substantial, although the RCTs demonstrated a lower ROB than the retrospective cohort studies. BCs demonstrated superior electrolyte profiles and comparable safety compared with NS in DKA. However, their effect on clinically meaningful outcomes such as time to DKA resolution remains uncertain. While the biochemical advantages support consideration of BC, definitive practice recommendations await higher-certainty evidence.

Diuretics are integral in fluid de-resuscitation of ICU patients following initial stabilization. While loop diuretics are commonly used, sequential nephron blockade (SNB) is an alternative diuretic strategy that combines a loop diuretic with at least one diuretic from another pharmacologic class to increase efficacy and limit adverse effects. The objective of this study was to compare the safety and efficacy of SNB to loop diuretics alone for de-resuscitation of critically ill patients. This retrospective study included adult ICU patients who received either a loop diuretic alone or combined with an aldosterone antagonist, carbonic anhydrase inhibitor, and/or thiazide diuretic on two consecutive days. The primary outcome was comparison of diuretic efficacy, assessed by urine output, on diuresis day 1. Secondary outcomes included comparison of diuretic efficacy on diuresis days 2-5 and incidence of acute kidney injury and electrolyte abnormalities on diuresis day 1. A total of 100 patients were included (SNB = 15, Loop = 85). At baseline, SNB patients had more hypernatremia (20% vs 2.4%, P = 0.023) and hyperchloremia (20% vs 2.4%, P = 0.023). Patients in the SNB group had increased urine output on diuresis day 1 (4725 vs 2215 mL, P = 0.0004). AKI did not occur in SNB patients on diuresis day 1 vs 15.5% of loop patients (P = 0.208). Hypernatremia (26.7% vs 2.4%, P = 0.004) and hyperchloremia (13.3% vs 3.5%, P = 0.161), persisted in the SNB group on diuretic day 2. In conclusion, among ICU patients requiring de-resuscitation, SNB may be associated with improved diuresis and similar safety concerns compared to loop diuretics alone.

The present study describes a rare and extreme case of prolonged survival in domestic sheep (Ovis aries) under severe natural conditions, designated as the "Monyak" case (March 2026, Eastern Rhodope Mountains, Bulgaria). A 90-day period of complete isolation involving two adult ewes and a subsequently born lamb on an inaccessible rocky ledge, with very limited access to sources of food or water, was documented. Clinical assessment performed immediately following rescue revealed profound dehydration and cachexia accompanied by multisystemic abnormalities suggestive of a prolonged catabolic state. Biochemical analysis demonstrated marked azotemia, characterized by elevated serum urea and creatinine concentrations, which may indicate reduced renal perfusion and intensified protein catabolism. Electrolyte disturbances, including hypernatremia and hyperchloremia, were compatible with severe dehydration and substantial disruption of water-electrolyte homeostasis. Furthermore, increased total serum protein concentration and hematocrit values were observed, consistent with pronounced hemoconcentration. The metabolic profile demonstrated alterations in glucose homeostasis together with enhanced ketogenesis, findings compatible with an adaptive metabolic response to sustained energy deprivation. Elevated serum activities of aspartate aminotransferase (AST) and alanine aminotransferase (ALT), accompanied by increased cortisol concentrations, may reflect hepatocellular stress and activation of the hypothalamic-pituitary-adrenal (HPA) axis associated with chronic physiological stress. Hematological evaluation revealed neutrophilia and lymphopenia, constituting a leukocyte pattern compatible with a stress leukogram and suggestive of endogenous glucocorticoid stimulation. Morphological examination of peripheral blood smears demonstrated pronounced echinocytosis and increased relative cellular density secondary to plasma volume depletion associated with dehydration. Additionally, neutrophilic hypersegmentation was observed, consistent with chronic physiological stress and cellular exhaustion. Ethological assessment suggests that maternal behavior and instinctive maternal care played a pivotal role in ensuring neonatal survival under conditions of extreme resource scarcity and sustained environmental stress. In conclusion, the "Monyak" case provides a unique natural model for investigating the physiological, metabolic, and behavioral adaptive mechanisms of ruminants subjected to prolonged starvation, dehydration, and chronic stress. The findings contribute valuable insights to veterinary physiology, clinical pathophysiology, and ethology, with potential implications for understanding the limits of adaptive capacity and survival under extreme environmental conditions.