REBEL Core Cast 26.0 – Lactated Ringers

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Think of IV Fluids as Medication!!!

0.9% Saline

• Content
• • Sodium 154
  • Chloride 154
  • pH 5.7
• Has been shown to start an inflammatory cascade in animal models.

Lactated Ringers

• Content
  • Sodium 130
  • Chloride 109
  • Potassium & lactate in small amounts
  • pH 6.4

SPLIT Trial

• No difference between 0.9% saline and balance fluid in terms of AKI
• Found equal occurrence of renal replacement therapy and mortality

SALT-ED Trial

• Looked at a primary outcome of hospital free days, no diff between two fluids.
• Lower incidence of major adverse kidney events at 30 days (MAKE-30) with balanced solutions

SMART Trial

• MAKE-30 (primary outcome) lower in balanced solution group

Read the critiques of the articles but it looks like there is a signal in the data showing increased adverse kidney events with 0.9 saline in comparison to balanced solutions

In the studies patient were getting modest amount of fluids. Outcomes may be worse if larger amounts of fluids are given.

In patients getting 1L of fluid it likely doesn’t matter much which of the fluid types you’re giving. However, if you think you will be giving a significant amount of fluid to say a patient with DKA or HHS please consider using a balanced solution

LR Considerations

• • Medications that can’t go in the same IV line
    • Ampicillin
    • Carbapenems
    • Phenytoin
    • Potassium Phosphate
    • Nicardipine
  • Can infuse in the same patient at the same time in different lines in different limbs
  • Ceftriaxone 
    • Can infuse in adults in different lines in different limbs as above
    • Shouldn’t infuse with LR even in seperate lines in kids under 28 days of age

Lactate Levels

• Not a significant amount of data but believed that lactate might increase slightly with lactated ringers infusion.

Take-Home Points

• When compared to Normal 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 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.

For More On This Topic

• REBEL EM: What the fluid?
  
• REBEL EM: Does LR Raise Serum Lactate? 
• NEJM: SPLIT Trial
• NEJM: SMART Trial
• NEJM: SALT-ED Trial

Shownotes Written By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)