Rebellion in EM 2019: What the Fluid? Wieters vs Bryant

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.

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

 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 1^st1 – 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:

1. Self WH et al. Balanced Crystalloids Versus Saline in Noncritically Ill Adults. NEJM 2018 [Epub Ahead of Print]
2. Semler MW et al. Balanced Crystalloids Versus Saline in Critically Ill Adults. NEJM 2018. [Epub Ahead of Print]
3. 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
4. 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]
5. 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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