January 29, 2020

Take Home Points

  • When compared to 0.9% saline, lactated ringers is a more balanced solution and more closely resembles our serum.
  • SALT ED and SMART trials show normal saline may increase the occurrence of major adverse kidney events in comparison to a balanced solution like LR. For large volume resuscitations, LR is a better choice.
  • Certain medications cannot be run with LR in the same IV line. Ampicillin, Carbapenems, Phenytoin, Potassium Phosphate, Nicardipine
  • Ceftriaxone and LR should never be running at the same time in children less than 28 days old.

October 10, 2019

Background: Serial lactate measurements is a common core measure that we follow in septic shock resuscitation. A number of readers have written in enquiring about whether resuscitation with lactated ringers instead of 0.9% saline would lead to increases in serum lactate.   It’s a great question, and one that I am not sure I had a solid answer for before reviewing this topic.  LR contains 28 mmol/L of sodium lactate and, on the surface, it seems reasonable to think that infusion of LR would lead to lactate increases. This could potentially confound the interpretation of serial serum lactate measurements.

August 26, 2019

Normal saline started being used based on work done in the 1830s with cholera.  We are still doing the same thing the same way and it’s not until recently we have begun to ask the hard questions about why we are doing things the same way 150 years later.  In this debate, titled "What the Fluid," from Rebellion in EM 2019, Scott Wieters, MD and Rob J. Bryant, MD debate the pros and cons of balanced and unbalanced crystalloids.

February 28, 2018

Background:  Normal Saline (NS) is one of the most commonly used IVFs in resuscitation today.  The use of balanced vs unbalanced crystalloids has been one of the biggest debates in resuscitation of the critically ill in recent history due to concerns of unbalanced fluids causing acute kidney injury, hyperchloremic metabolic acidosis,  and worsened mortality.  In 2015, we saw the publication of the SPLIT trial, which we covered on REBEL EM. This was a randomized clinical trial of over 2200 patients in 4 ICUs in New Zealand comparing 0.9% Saline (NS) vs Plasma-Lyte.  This trial had many issues including, >70% of patients coming from the OR, only 15% came from the ED, only 4% had sepsis, and the biggest issue with this trial was that the majority of patients only received 1 – 2L of NS, making it unclear if larger volumes of unbalanced crystalloid would have worsened morbidity and mortality.  Since the publication of this study, two more trials have been published: The SALT-ED Trial and The SMART trial (Both Just published in the NEJM Feb 27th, 2018).