NS v LR docket number 15879562

[pbruss]

what iv fluids should we be using? namely when should we be using normal saline and when should we be using LR? what evidence or literature can is out there to support one over the other?

would like to get everyones input.

[Bjs04f]

LR rocks.
1- www.ncbi.nlm.nih.gov/pubmed/16832250. IN trauma setting an improvement in blood loss and ease of resuscitiation is seen with LR
2-0.9% NS causes a normal anion gap hyperchloremic acidosis as well as moderating coagulation in
models of hemorrhage (elevated serum coagulation levels, decreased fibrinogen, and increased
blood loss) compared with LR a
3-There are conflicting results on the efficacy of NS on retained volume resuscitation, although most
studies suggest LR and Albumin have better responses (in terms of MAP and BP) with less
volume of solution administered. Normal saline appears to have greater response in urinary output
O’Malley, Catherine M.N., Frumento, Robert J., et al. “A Randomized, Double-Blind Comparison of lactated
Ringer’s and 0.9% Normal Saline During Renal Transplantation.” Anesth Analg 2005; 100: 1518-24
5. Waters, Jonathan H., Gottlieb, Alexandru, et al. “Normal Saline Versus Lactated Ringer’s Solution for Intraoperative
Fluid Management in Patients Undergoing Abdominal Aortic Aneurysm Repair: An outcome Study.” Anesth Analg:
2001; 93:817-822
6. Baker, Andrew J, Park, Eugene, et al. “Effects of Resuscitation Fluid on Neurologic Physiology After Cerebral
Trauma and Hemorrhage.” J trauma 2008; 64: 348-357
7. Healy, Mark, Davis, Richard, et al. “Lactated Ringer’s Is Superior to Normal Saline in a Model of Massive
Hemorrhage and Resuscitation.” J Trauma; 1998: 45(5); 894-899
8. Kiraley, Laszlo, Differding, Jerome A., et al. “Resuscitation with Normal Saline (NS) vs. Lactated Ringer’s (LR)
Modulates Hypercoagulability and Leads to Increased Blood Loss in an Uncontrolled Hemorrhagic Shock Swine
Model.” J Trauma; 2006: 61; 57-65
9. Todd, S. Rob, Malinoski, Darren, et al. “Lactated Ringer’s is Superior to Normal Saline in Resuscitation of
Uncontrolled Hemorrhagic Shock.” J Trauma: 2007; 62: 636-639
10. Philips, Charles R., Vinecore, Kevin, et al. “Resuscitation of haemorrhagic shock with normal saline vs. lactated
Ringer’s: effects on oxygenation, extravascular lung water, and haemodynamics.” Critical Care: 2009: 13;R30
11. McIntyre, Lauralyn, Hébert, Paul, et al. “A survey of Canadian intensivists’ resuscitation practices in early septic
shock.” Critical Care: 2007; 11(R7)

[Bjs04f]

I think overall LR is more physiologic and beneficial in damn near every setting. Once I was told not to use it in DKA as the pt had K of 6.0. As a note in 1L of LR theres like 5 mmol K, so super minimal effect. Also have been told lactate becomes acid which it doesnt, so a lot of misconception. i think the big thing is its more expensive and were always taught dump NS and youre set.

[pbruss]

nocely done, kemple says he can convince us that you are full of shit but has to come back from VACA first

[pbruss]

we'll see what kemple says but i found a nice review (see attached)

Attachments:

NSvLR.pdf (480.84 KB)

[kemple]

I think that everything has it's place.

**In pt with renal insufficiency and high K yes it's only 4 mmol/L or LR, but that's 4meq and when we use up to 4 or 5 liters a day you are adding potentially 20meq of K+ to a pt with high K+. That will make it more difficult to reduce and could potentiate complications. Something to think about.


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Effects of Normal Saline vs. Lactated Ringer's during Renal Transplantation
2008, Vol. 30, No. 5 , Pages 535-539 (doi:10.1080/08860220802064770)

**Increased rates of thromboembolic events with LR compared to NS.


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Arrhythmia/Electrophysiology
Pilot Randomized Clinical Trial of Prehospital Induction of Mild Hypothermia in Out-of-Hospital Cardiac Arrest Patients With a Rapid Infusion of 4°C Normal Saline

**Fluid of choice for post resuscitation cooling in prehospital setting.


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Resuscitation with balanced electrolyte solution prevents hyperchloremic metabolic acidosis in patients with diabetic ketoacidosis ☆ ☆☆
Simon A. Mahler, MD, , Steven A. Conrad, MD, PhD, Hao Wang, MD, PhD, Thomas C. Arnold, MD
Show more
doi:10.1016/j.ajem.2010.02.004

**Take home point is yes LR has less chloremia, but there is no proven clinical benefit. I would argue use what you have in good supply and readily available if M&M is not shown to be affected.

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This is reinforced with the article Bruss posted "The review concludes that dilutionalhyperchloraemic
acidosis is a side eff ect, mainly
observed after the administration of large volumes of
isotonic saline as a crystalloid. Its eff ect is moderate
and relatively transient, and is minimised by limiting
crystalloid administration through the use of colloids
(in any carrier). Convincing evidence for clinically
relevant adverse eff ects of dilutional-hyperchloraemic
acidosis on renal function, coagulation, blood loss,
the need for transfusion, gastrointestinal function
or mortality cannot be found. In view of the longterm
use of isotonic saline either as a crystalloid or
as a colloid carrier, the paucity of data documenting
detrimental eff ects of dilutional-hyperchloraemic
acidosis and the limited published information on the
eff ects of balanced solutions on outcome, we cannot
currently recommend changing fl uid therapy to the
use of a balanced colloid preparation."

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pulmccm.org/2012/randomized-controlled-trials/normal-saline-toxic-to-kidneys-chloride-solutions-may-cause-renal-failure-jama/

*While NS may increase rates of renal insufficiency, no change to rates of needing dialysis post d/c. Again no M&M changes.


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Comparisons of normal saline and lactated Ringer’s resuscitation on hemodynamics, metabolic responses, and coagulation in pigs after severe hemorrhagic shock
Wenjun Z Martini*, Douglas S Cortez and Michael A Dubick

Corresponding author: Wenjun Z Martini [e-mail]

Author Affiliations
US Army Institute of Surgical Research, JBSA Ft, 3698 Chambers Pass, Sam Houston, TX 78234, USA

For all author emails, please log on.

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013, 21:86 doi:10.1186/1757-7241-21-86



*NS returned hemodynamic status quicker, but required more fluid to do so 6.1 vs 4.6L respectively. There was a larger amount of acidosis with NS but again
there was no proven M & M difference.


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Fluid management in diabetic-acidosis—Ringer's lactate versus normal saline: a randomized controlled trial

D.G. Van Zyl , P. Rheeder , E. Delport
DOI: dx.doi.org/10.1093/qjmed/hcr226 337-343 First published online: 22 November 2011

**No benefit of LR in fact took longer to achieve normal pH and BGL of 14mmol/L.

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The Effect of Normal Saline Solution, Ringer's Lactate Solution, and Distilled Water on the Lungs of Dogs and Rabbits*
Herbert C. Miller, Tom R. Hamilton, George W. Wise, and Herbert A. Wenner
Author information ► Copyright and License information ►

**Just for S's and G's, NS is better on rabbit lungs

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Indian Pediatrics
December 2012, Volume 49, Issue 12, pp 963-968
Date: 30 Mar 2012
Ringer’s lactate vs normal saline for children with acute diarrhea and severe dehydration: A double blind randomized controlled trial
Vidushi Mahajan, Shiv Sajan Saini, Amit Sharma, Jasbinder Kaur

**No difference in pH improvement with LR over NS when used in children with acute dehydration.


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Overall point, while there is some difference on immediate effects with both NS and LR, there are no changes to M&M and the cost is cheaper for NS. I will continue to use NS until more evidence conclusively shows difference to M&M. Oh yeah my sources are newer than yours.

[Bjs04f]

$0.18... Worth it. Do it because Scotty said so.http://boringem.org/2013/01/06/normal-saline-the-coke-of-crystalloid-fluids/

[pbruss]

i do think i am going to start using LR for my patients who need more then 1 liter of flud. but for everyday stuff im sticking with NS