Rebellion in EM 2019: What the Fluid? via Scott Wieters, MD & Rob J. Bryant, MD
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Scott Wieters, MD (@EmedCoach) – Pro Balanced Fluids
- Normal saline is actual Abnormal Saline Solution (ASS).
- Our bodies plasma concentration has Na, Cl, K, Mg, Ca, Bicarb, and lactate in varying concentrations
- What does NaCl consist of? 154 of Na and 154 of Cl. This is not normal compared to plasma
- Normal saline is a bit acidic with a pH of about 5.6.
- What else is also acidic? Coffee (pH 5.0) and Beer (pH 4.5).
- Normal Saline promotes acidosis
- Normal saline induces a cascade of inflammatory markers
- It’s been shown in rat and sheep models that NS leads to a bump in inflammatory markers
- Normal Saline has been shown to be harmful to our kidneys
- Salt-ED trial showed increased Major Adverse Kidney Events at 30 Days. This was driven by increased creatinine levels with NS compared to BC.
- SMART trial has shown that in sepsis related deaths NS was associated with increased mortality compared to more balanced solutions:
- Sepsis Mortality: NS 29.4% vs BC 25.2%
- Sepsis MAKE30: NS 38.9% vs BC 33.8%
- Bottom Line: Normal Saline is NOT Superior to Balanced Crystalloids. If you think NS is NORMAL…You’re an ASS (Abnormal Saline Solution)
Rob Bryant (@RobJBryant13) – Pro Normal Saline
- Asking all of medicine to completely switch from NS to BC in all instances is just silly
- Normal Saline is NOT an Abnormal Saline Solution (ASS)…it’s an ARSE (Always Rely on Saline Everytime)
- There are a variety of medications that have contraindications or relative contraindications to being given with LR:
- Rocephin + LR can in theory can harm patients:
- Calcium in LR can bind to Rocephin and lead to deposits in the lungs & kidneys (in theory)
- Other medications include:
- Amiodarone
- Rocephin
- Diltiazem
- Invanz
- Ketamine
- Levaquin
- Nicardipine
- Zosyn
- Kcentra
- TXA
- Salt-ED trial showed that LR was equal to NS in its primary outcome of hospital free days
- Sure, there was a small bump in creatinine and acute kidney injury, but did patients die? No.
- SMART trial showed increased mortality with NS
- However, its only one trial that showed any difference. This is in a similar vain to the NINDS trial that was practice altering. Perhaps we need more data before making this practice changing switch
- SPLIT trial showed no difference between LR and NS
- AKI: 9.6% vs 9.2%
- RRT: 3.3% vs 3.4%
- Mortality: 7.6% vs 8.6%
- Chinese meta-analysis by Liu et al, including 9 studies with 20,526 patients showed:
- No difference between BC vs NS in Death, AKI, RRT and ICU length of stay
- Salt-ED trial also showed that there was no difference in fluids bumping creatinine in the first few hours of resuscitation (i.e. <2L of fluid)
- Bottom Line: At this point in time it appears if you are using NS or a BC as your resuscitation fluid of choice keep using your fluid of choice
- Rocephin + LR can in theory can harm patients:
Scott Wieters – Rebuttal
- We need to know when to appropriately give BC:
- Doing something “everytime” is extreme. I don’t use LR in neonates, pts with hyperkalemia, head injuries, or sodium channel OD
- If concerned for inability to give certain medications with LR, perhaps you should obtain another line of access
Rob J. Bbyant – Rebuttal
- Patients don’t present to the ED with a diagnosis tattooed on their foreheads.Many of them are undifferentiated. For the undifferentiated hypotensive patient that comes to the ED we should probably initially resuscitate them with NS (for the 1st1 – 2L). We don’t know what pathology is causing their symptoms so it’s safe to resuscitate with NS. Once the cause/diagnosis has been learned we can switch to appropriate fluids
References:
- Self WH et al. Balanced Crystalloids Versus Saline in Noncritically Ill Adults. NEJM 2018 [Epub Ahead of Print]
- Semler MW et al. Balanced Crystalloids Versus Saline in Critically Ill Adults. NEJM 2018. [Epub Ahead of Print]
- Yunos NM et al. Association Between a Chloride-Liberal vs Chloride-Restrictive Intravneous Fluid Administration Strategy and Kidney Injury in Critically ill Adults. JAMA 2012. PMID: 23073953
- Liu C et al. Balanced Crystalloids Versus Normal Saline for Fluid Resuscitation in Critically Ill Patients: A Systematic Review and Meta-Analysis with Trial Sequential Analysis. AJEM 2019. [Epub Ahead of Print]
- Young P et al. Effect of a Buffered Crystallid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit: The SPLIT Randomized Clinical Trial. JAMA 2015; E1 – E10. [epub ahead of print]
Shownotes Written By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)
Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)
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