Lactated Ringer vs. Normal Saline

[zeloc]

Like many IM-trained physicians, I have extensively used NS. However, I am wondering if I should just switch to LR. There are specific areas in which studies have shown likely superiority of LR to NS (eg, pancreatitis). It is more physiologic. It won't cause a normal anion gap metabolic acidosis.

For a hospitalist, is there any situation where NS is better than using LR (except for a hypercalcemic pt)?

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[Raryn]

Like many IM-trained physicians, I have extensively used NS. However, I am wondering if I should just switch to LR. There are specific areas in which studies have shown likely superiority of LR to NS (eg, pancreatitis). It is more physiologic. It won't cause a normal anion gap metabolic acidosis.

For a hospitalist, is there any situation where NS is better than using LR (except for a hypercalcemic pt)?

Patients at risk for brain edema is the big one. In-line use with blood transfusions is another (this may not be supported well, but show me a hospital that doesn't have a policy against LR and blood in the same line). I can't think of too much else where NS is theoretically superior to LR.

 

[obiwan]

Like many IM-trained physicians, I have extensively used NS. However, I am wondering if I should just switch to LR. There are specific areas in which studies have shown likely superiority of LR to NS (eg, pancreatitis). It is more physiologic. It won't cause a normal anion gap metabolic acidosis.

For a hospitalist, is there any situation where NS is better than using LR (except for a hypercalcemic pt)?

Theres the SALT/SMART trials that recently came out

 

[HoldTheCoffee]

During my IM training, LR was used a lot in the ICU, especially in patients who needed large volumes of fluid. On the regular wards, NS was more common. There are definitely institutional preferences though. During my fellowship, I suggested switching to LR because a patient was developing NAGMA and I got a lot of strange looks

 

[Psai]

During my IM training, LR was used a lot in the ICU, especially in patients who needed large volumes of fluid. On the regular wards, NS was more common. There are definitely institutional preferences though. During my fellowship, I suggested switching to LR because a patient was developing NAGMA and I got a lot of strange looks

For people who obsess over minutiae, the lack of understanding about fluids is something that always blows my mind

 

[cbrons]

The best fluid is no fluid at all unless you have an actual fluid-losing problem or low amounts in someone who is volume responsive. That being said, dka is another area where LR is far superior to NS given the volumes sometimes needed, you get them out of DKA faster by not adding a hyperchloremic acidosis with NS.

 

[NewYorkDoctors]

The worst offenders are “maintenance fluids.”
I tell the housestaff that unless one is hypovolemic, a patient should never get “maintenance fluids.” If npo , can give d5w at 40mL/hr to cover for 1L of insensible losses .

When I tell them to inform me how many grams of salt (NaCl) can be desiccated from 1L of NS and they find out the answer (9grams ) , they begin to chill out

 

[jdh71]

Like many IM-trained physicians, I have extensively used NS. However, I am wondering if I should just switch to LR. There are specific areas in which studies have shown likely superiority of LR to NS (eg, pancreatitis). It is more physiologic. It won't cause a normal anion gap metabolic acidosis.

For a hospitalist, is there any situation where NS is better than using LR (except for a hypercalcemic pt)?

Sick heads are really the only reason to use NS for fluids if you need to give it at all.

As a hospitalist if you are taking care of sick heads you should find a new job. They are asking too much.

 

[Raryn]

The worst offenders are “maintenance fluids.”
I tell the housestaff that unless one is hypovolemic, a patient should never get “maintenance fluids.” If npo , can give d5w at 40mL/hr to cover for 1L of insensible losses .

When I tell them to inform me how many grams of salt (NaCl) can be desiccated from 1L of NS and they find out the answer (9grams ) , they begin to chill out

If one is truly NPO, there's insensible salt losses too. The kidney can only do so much. Might not matter much for a day or so, but some patients are NPO for much longer.

I don't put patients on D5W unless they're hypernatremic.

 

[NewYorkDoctors]

If one is truly NPO, there's insensible salt losses too. The kidney can only do so much. Might not matter much for a day or so, but some patients are NPO for much longer.

I don't put patients on D5W unless they're hypernatremic.

True sweat is about 50mEq/L of Na and the stools are 30mEq/L of sodium under normal circumstances . Hence D51/2NS May be better.

But if the NPO is so prolonged, perhaps for dysphagia pending a PEG and trach , the best thing is Enteral feeding with water flushes anyway over “maintenance fluids.”

 

[Psai]

True sweat is about 50mEq/L of Na and the stools are 30mEq/L of sodium under normal circumstances . Hence D51/2NS May be better.

But if the NPO is so prolonged, perhaps for dysphagia pending a PEG and trach , the best thing is Enteral feeding with water flushes anyway over “maintenance fluids.”

No. D50.5ns causes more hyponatremia with no benefit, assuming competent kidneys

 

[blub1212]

At my institute, normosol is the same price as NS and LR, so I almost always use normosol. There are a small handful of specific times that I will use NS, if we have a shortage of normosol for whatever reason then I will use LR. A lot of the older IM attendings still use NS though......

 

[Siggy]

The worst offenders are “maintenance fluids.”
I tell the housestaff that unless one is hypovolemic, a patient should never get “maintenance fluids.” If npo , can give d5w at 40mL/hr to cover for 1L of insensible losses .

When I tell them to inform me how many grams of salt (NaCl) can be desiccated from 1L of NS and they find out the answer (9grams ) , they begin to chill out

I can't tell the number of times the following conversation goes on:

RN: "The patient's blood pressure is out of control, can we get an order for PRN hydralazine?"
Me: "How about we just stop the fluids?"
RN: "???"
Me: "Well, we are giving him more than a 2L bottle of salt water in a day directly into his veins."