Lactated Ringers . .

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Homunculus

Homunculus

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so what d'yall think about it? pros and cons? we had a rather . . "boisterous" discussion about it the other day in our department and i'm curious as to what the EM folks opinions were-- or what your local uses for it are.

i'll add my input later 😀

--your friendly neighborhood hopefully conversation inducing caveman
 
I use NS on almost everything, but that's because I think it takes less ink to write "NS" than "LR."

Oh wait, I'm probably wrong just looking at that font.

Q
 
If you don't work in a major trauma center, your nurses may not even remember where the LR is.
 
QuinnNSU said:
I use NS on almost everything, but that's because I think it takes less ink to write "NS" than "LR."

Oh wait, I'm probably wrong just looking at that font.

Q
Click to expand...

On the ambulance, we were always required to use LR on burn patients. Do burn centers typically use LR?
 
I think NS is fine for your standard ED resuscitation.

I think when you get to the resuscitations that need liters on end, I vaguely remember our trauma/burn surgeons preferring LR to prevent hyperchloremic acidosis (?). By then they should be long gone out of the ED anyhow and the surgeons have their preferred brand flowing.......
 
spyderdoc said:
I think NS is fine for your standard ED resuscitation.

I think when you get to the resuscitations that need liters on end, I vaguely remember our trauma/burn surgeons preferring LR to prevent hyperchloremic acidosis (?). By then they should be long gone out of the ED anyhow and the surgeons have their preferred brand flowing.......
Click to expand...
Any patient receiving massive amounts of fluids should get LR, but only if they have signs of developing a hyperchloremic acidosis (i.e., their BMP results).

LR in trauma patients isn't a great idea since the calcium additive makes it imcompatible with most blood products.
 
We used LR on the ambulance only for drunks normally and for burn victims, but the ED docs didn't get too pissy with us for bringing in a burn pt with NS hanging. After all, it's easy enough to switch over if that becomes necessary.
 
Everywhere I have ever worked or been a part of medical care, LR has been used for fluid resuscitation: in the field, OR and ER. NS was used for "medical patients" for drips and maintenance and resuscitation of those in DKA.


I have always wondered if anyone has actually studied or tested whether LR would cause coagulation with blood or not. I tend to think it is theoretical but have been too lazy to look it up.
 
NS has 154 meq of sodium which, if used for large fluid resuscitations, will portend a hypernatremic state. In addition, it does not contain Potassium, which will wash out when large amounts of NS are given. LR has a lower sodium equivalent (~140meq) and also contains 3meq of KCl, which is excellent for large volume resuscitation because the sodium is physiologically balanced and the potassium may trend towards, but will never drop below 3. LR is also beneficial for volume resuscitation in patients with head trauma where sodium balance is important. NS is excellent for resuscitations alone where large volume infusion is not required....
 
We do shy away from LR for large volume resus for those that are CRI or in CRF.
 
DrDre' said:
I have always wondered if anyone has actually studied or tested whether LR would cause coagulation with blood or not. I tend to think it is theoretical but have been too lazy to look it up.
Click to expand...

The only resultd I have found regarding this:

Edwards MP; Clark DJ; Mark JS; Wyld PJ: Compound sodium lactate (Hartmann's) solution. Caution: risk of clotting. Anaesthesia 1986 Oct; Vol. 41 (10), pp. 1053-4.

Abstract: We have observed blood clotting in blood administration sets where Hartmann's solution (Travenol) has preceded blood transfusion. This is due to calcium ions (Ca++) contained in the Hartmann's solution and is more likely to occur at 37 degrees C. We suggest that this potential hazard be more widely realised and that the practice cease.

=============================
Lorenzo M; Davis JW; Negin S; Kaups K; Parks S; Brubaker D; Tyroch A: Can Ringer's lactate be used safely with blood transfusions? Am J Surg] 1998 Apr; Vol. 175 (4), pp. 308-10

BACKGROUND: Blood bank recommendations specify that Ringer's lactate solution (LR) should be avoided while transfusing blood. However, there are few studies either evaluating or quantifying increased coagulation during rapid infusion of LR and blood. DESIGN AND METHODS: Whole blood (WB, n = 25) and packed red blood cells (PRBC, n = 26) were rapidly admixed with normal saline (NS), Lactate solution and LR with 1 g (LR-1), 2 g (LR-2), and 5 g (LR-5) CaCl2/L solutions for assessment of infusion time, filter weight, and clot formation. RESULTS: No significant differences in infusion time or filter weight using WB or PRBC with NS or LR were seen. No significant difference in clot formation between NS and LR with WB or PRBC was found, but the presence of visible clot was increased in the LR-5 group (P = 0.013, WB, and P = 0.002, PRBC). CONCLUSION: A comparison of LR and NS with rapid infusion rates of blood showed no significant difference between infusion time, filter weight and clot formation. Blood bank guidelines should be revised to allow the use of LR in the rapid transfusion of PRBC.

================
Ryden SE; Oberman HA: Compatibility of common intravenous solutions with CPD blood. Transfusion 1975 May-Jun; Vol. 15 (3), pp. 250-5.

Blood anticoagulated with CPD was mixed with lactated Ringer's solution, 5 per cent aqueous dextrose, 5 per cent dextrose in 0.225 per cent saline, 5 per cent dextrose in 0.9 per cent saline, and 0.9 per cent saline solution in varying concentrations and incubated at room temperature and 37 C. Clots formed in the blood-lactated Ringer's mixture after five minutes at a citrate:calcium molar ratio of 4:1 or lower. Aqueous dextrose-blood mixtures showed immediate clumping with gross hemolysis after 30 minutes incubation. Blood mixed with 5 per cent dextrose and 0.225 per cent saline hemolyzed within ten minutes incubation at 37 C. No hemolysis occurred in blood mixed with 5 per cent dextrose in 0.9 per cent saline or with 0.9 per cent saline. Traces of solutions labeled with Evans blue dye remained in intravenous administration tubing even 30 minutes after a simulated transfusion was begun. Lactated Ringer's solution and 5 per cent dextrose in 0.225 per cent saline should not be administered concurrently with blood. Lactated Ringer's solution may also be harmful when used to start transfusions as it rapidly produces clots when mixed with CPD blood.
==================================
 
southerndoc said:
LR in trauma patients isn't a great idea since the calcium additive makes it imcompatible with most blood products.
Click to expand...
I did a quick pubmed and medline search and found that wasn't the case (I did it about a year and a half ago)... although you will still see in the textbooks (and often what your attendings say) that the Ca++ is incompatible with PRBCs and the such.

Q
 
I've been taught that LR has a pH of 6.5 and NS has a pH of 5. Therefore, it's used in trauma pts since they don't usually need help becoming acidotic, the exception being isolated head trauma since NS has a higher osmolarity and is thus less likely to cause edema.

Note: everything above is level 5 evidence. I'm guessing there's some sort of something that resembles evidence to back this up since the guy loves EBM, but I've never actually looked for it.
 
Weird. I am apprently the only one who has pretty much only seen NS used almost exclusively in the ED and on EMS units.

Our ambulance service pulled all LR years ago before I even started working for them. NS only.

I've worked in both suburbia (level II trauma) ED's and a Level I academic ED full-time. Always NS (since I was the one spiking the bags).

You guys really use alot of LR in the ED for routine stuff? or just for massive fluid resuscitations.

just got done doing an away rotation at a academic EM program and no LR there either. Also my school's ED doesn't really use much LR.

What do you guys typically use for the run-of-the-mill needs a couple of Liters of hydration patients (ie. stone patients)?

later
 
spyderdoc said:
I think NS is fine for your standard ED resuscitation.

I think when you get to the resuscitations that need liters on end, I vaguely remember our trauma/burn surgeons preferring LR to prevent hyperchloremic acidosis (?). By then they should be long gone out of the ED anyhow and the surgeons have their preferred brand flowing.......
Click to expand...
The quantitative approach (or Stewart approach) to acid-base disorders is nicely discussed on these websites. After reading these, it should be apparent why physiological solutions are "theoretically" preferred over (ab)normal saline.

http://www.anaesthetist.com/icu/elec/ionz/Stewart.htm
http://www.acid-base.com/strongion.php
http://www.acidbase.org/index.php?show=sb
http://www.ccm.upmc.edu/education/resources/phorum.html


You also can do a medline search with the terms Strong Ion Difference (or SID), and acidosis. Anything written by JA Kellum, Story, Bellomo, Kaplan is very good.

I HIGHLY recommend anyone remotely interested in acid-base problems to read and understand this approach. It really opens up your eyes to another way to appreciate acid-base problems.

KG
 
I used D5 1/2 NS (with or without 20 meq K) on the floors or .9 NS. Never LR. I think the nurses feared the stuff.

Now in the OR's its exclusively LR unless hanging blood or pt with renal failure.

For rapid resucitation I doubt it makes any difference. Just get the fluid in. Otherwise I've been taught that LR is more physiologic and it helps avoid hyperchloremic metabolic acidosis (.45 NS will fix that anyhoots so no biggie).

I guess if yer hanging LR as your MF you may forget about the K it has in it and you could possibly get into trouble when you have drips added to it. Additionally the calcium may bind up some drugs lowering their bioavailability.


Acid Base, Fluids, and Electrolytes made Ridiculously Simple worked for me. Too bad I forgot about 90% of it.

Now how bout colloids...muhahahah
 
so the consensus here (at a peds dept) was overwhelmingly anti-LR. that's putting it mildly (a few of our staff were quite vehement in their "LR is teh debil" stance)

the primary reasons seemed to be these:

LR contains 130 mEq Na-- NS is 154. While it would seem better to use LR due to being closer to physiologic this extra sodium actually helps pull more fluid intravascularly, which is where you want it.

LR contains 28 mEq lactate- which in healthy individuals will be hepatically turned into bicarbonate and may serve to buffer an acidosis. however, *if* you are truly using LR as a resuscitation soln, chances are your end organs aren't performing quite up to par-- and the lactate will only worsen your acidosis.

honestly i've never used LR-- surgeons like it, but i haven't seen it much in peds cases.

LR or NS, just don't bolus with D5 1/2NS. Outside ED doc did that the other day (kid was fine) and some of our staff almost imploded, lol. also, if a kid is PO intolerant don't drop an NG and give him a 20cc/kg bolus of NS via NG. (still don;t know where that one came from-- maybe it's a new thing i haven't heard of)

so anyay, i'd like to find some good articles on this, because i like to be the devil's advocate on these things and may do a journal article presentation on it at my program. it's always fun bringing up things that start passionate discussions 🙂 😎

thanks everyone for their input 👍

--your friendly neighborhood maintenence fluid ordering caveman
 
Homunculus said:
LR or NS, just don't bolus with D5 1/2NS. Outside ED doc did that the other day (kid was fine) and some of our staff almost imploded, lol. also, if a kid is PO intolerant don't drop an NG and give him a 20cc/kg bolus of NS via NG. (still don;t know where that one came from-- maybe it's a new thing i haven't heard of)
Click to expand...

See, now I just got off of a PICU rotation and they about went ballistic if you used anything BUT D5 1/2NS! I don't know that there is a whole lot of science to be fun here...

- H
 
FoughtFyr said:
See, now I just got off of a PICU rotation and they about went ballistic if you used anything BUT D5 1/2NS! I don't know that there is a whole lot of science to be fun here...

- H
Click to expand...

D5 1/2 NS is the standard for maintenence on most kids; D5 1/4NS for under 10 kg or so, with D5 1/3 NS a good compromise between the two. but you should never bolus with it AFAIK. were the PICU docs using it for resuscitation or maintenence?

--your friendly neighborhood oral electrolyte solution preferring caveman
 
Homunculus said:
so the consensus here (at a peds dept) was overwhelmingly anti-LR. that's putting it mildly (a few of our staff were quite vehement in their "LR is teh debil" stance)

the primary reasons seemed to be these:

LR contains 130 mEq Na-- NS is 154. While it would seem better to use LR due to being closer to physiologic this extra sodium actually helps pull more fluid intravascularly, which is where you want it.

LR contains 28 mEq lactate- which in healthy individuals will be hepatically turned into bicarbonate and may serve to buffer an acidosis. however, *if* you are truly using LR as a resuscitation soln, chances are your end organs aren't performing quite up to par-- and the lactate will only worsen your acidosis.

honestly i've never used LR-- surgeons like it, but i haven't seen it much in peds cases.

LR or NS, just don't bolus with D5 1/2NS. Outside ED doc did that the other day (kid was fine) and some of our staff almost imploded, lol. also, if a kid is PO intolerant don't drop an NG and give him a 20cc/kg bolus of NS via NG. (still don;t know where that one came from-- maybe it's a new thing i haven't heard of)

so anyay, i'd like to find some good articles on this, because i like to be the devil's advocate on these things and may do a journal article presentation on it at my program. it's always fun bringing up things that start passionate discussions 🙂 😎

thanks everyone for their input 👍

--your friendly neighborhood maintenence fluid ordering caveman
Click to expand...


Lactate is metabolized approximately 80% hepatically and roughly 20% renally. The normal functioning liver can metabolize roughly 2,000 mmol lactate per day. A huge load. If each liter of LR has 28 mmol of lactate in it how much do you think it would take to "overload" the liver?

You only really see exogenous lactate elevations when you run CRRT (continuous renal replacement therapy - continuous dialysis in an ICU setting) Some dialysate is buffered with lactate and after a day or so, the serum lactate will equilibrate with the dialysate (roughly 3 or 4 mmol/l).

The patient will NOT become acidotic from LR administration. Actually the contrary is true. Classic example is using LR for cardiac bypass, causes metabolic alkalosis. You will, however, most definitely become acidotic by large volume .9% saline infusion. Hyperchloremic metabolic acidosis is quite common.

If you really want a close to perfect solution, dissolve 3 amps of sodium bicarb (150 meq Na and 150 meq bicarb total) in a liter bag of D5W. Now you will get the intracellular benefit of Na without the acidosis associated with the chloride.

This is in adults. I'm sure it applies in a dose adjusted manner to kids as well.
A lit search on strong ion gap or strong ion difference will get you several articles, many were conducted in pediatric ICU's.

I'll attach an example of how Lactate and Chloride affect our immune system in drastically different ways. Not all acidoses are created equal.

kg
 

Attachments

KGUNNER1 said:
If you really want a close to perfect solution...
Click to expand...
(pun intended?)
KGUNNER1 said:
dissolve 3 amps of sodium bicarb (150 meq Na and 150 meq bicarb total) in a liter bag of D5W. Now you will get the intracellular benefit of Na without the acidosis associated with the chloride.
Click to expand...
didn't you mean intravascular? Also, infusing bicarb without strong indications, much stronger ones than acidosis prophylaxis, seems like a bad idea where I come from, but they could be wrong too.

I'm not trying to pick on you, but I've been hearing this debate for the whole three years I've been on the floors & I'm pretty sure that the reason it is still being debated is because nobody really knows what the right answer is. Obviously hyperchloremic metabolic acidosis is a clinical reality, but most of the rest of this stuff seems like mental masturbation to me...though I never said I had anything against masturbation.
 
DrDre' said:
Everywhere I have ever worked or been a part of medical care, LR has been used for fluid resuscitation: in the field, OR and ER. NS was used for "medical patients" for drips and maintenance and resuscitation of those in DKA.


I have always wondered if anyone has actually studied or tested whether LR would cause coagulation with blood or not. I tend to think it is theoretical but have been too lazy to look it up.
Click to expand...

After many, many CABGs and hanging countless PRBCs, I've yet to see a filter clog from LR + PRBC. Of course NS is preferred, but if we run out in the heart room and theres a LR bag there, I'll hang it without thinking twice.
 
WilcoWorld said:
(pun intended?)

didn't you mean intravascular? Also, infusing bicarb without strong indications, much stronger ones than acidosis prophylaxis, seems like a bad idea where I come from, but they could be wrong too.

I'm not trying to pick on you, but I've been hearing this debate for the whole three years I've been on the floors & I'm pretty sure that the reason it is still being debated is because nobody really knows what the right answer is. Obviously hyperchloremic metabolic acidosis is a clinical reality, but most of the rest of this stuff seems like mental masturbation to me...though I never said I had anything against masturbation.
Click to expand...


Yes, intraVASCULAR is what I meant. Thank you for picking this up.

I agree, infusing bicarb for the sole sake of correcting most acidoses has been shown to be futile at best, and potentially harmful. The ideal solution would contain the exact electrolyte composition of normal plasma. Something like "plasmalyte" but not as expensive.

What you really want is Na. As everyone here knows, Na carries a (+) charge and we need to add another (-) charge, of equal magnitude, to make a solution. This can either be done the easy and very cheap way (adding 154 meq of Chloride) or getting creative by mixing Cl-, with Lactate-, and/or bicarbonate. Lactate and bicarb go away rather quickly in an "open" system (one with adequate ventilation) however, Cl- hangs around. We are starting to realize that Cl- may not be as benign as we once thought. You may not see changes in Mortality, but morbidity may be increased when you cause hyperchloremic metabolic acidosis (decreases renal perfusion, causes nausea and vomiting, pro-inflammatory stimulus etc...)

So it would be great if we could just take it out of the equation. How much is too much you ask?

After about 2 or 3 liters, I switch over from NS to LR. I actually prefer to then add a colloid, Hextend (hetastarch dissolved in a physiologic solution, about the same cost as Hespan - which is hetastarch dissolved in NS).

And for those astute minds that follow this literature, this wasn't addressed in the SAFE trial published this past year in NEJM.

Cheers,
kg
 
So when we say that we get hyperchloremic metabolic acidosis after large volumes of NS, how do we define "large volumes? 2L? 5L? 10L?

'zilla
 
NinerNiner999 said:
NS has 154 meq of sodium which, if used for large fluid resuscitations, will portend a hypernatremic state. In addition, it does not contain Potassium, which will wash out when large amounts of NS are given. LR has a lower sodium equivalent (~140meq) and also contains 3meq of KCl, which is excellent for large volume resuscitation because the sodium is physiologically balanced and the potassium may trend towards, but will never drop below 3. LR is also beneficial for volume resuscitation in patients with head trauma where sodium balance is important. NS is excellent for resuscitations alone where large volume infusion is not required....
Click to expand...


Just a few things.
LR is 130meq of Na.
In head trauma, NS is preferred because of a few things. First, NS has a higher osmolality and therefore will lead to less edema (cerebral edema included). This is the idea behind hyprertonic saline for trauma resusitation. Secondly, lactic acid is formed during anaerobic glycolysis that takes place during ischemia. The decreased pH adds to the deterioration of the intracellular environment. Glucose may accelerate the process by adding substrate to the anaerobic glycolysis. If you remember from biochem, lactate + pyruvate = glucose. This is also true for tumors or any process in which perfusion to any part of the brain is compromised (hypotension).
 
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