What do you prefer - LR or NS?

[BaileyMoto]

And with that asked...any of you have any links to the most up to date studies regarding Lactated Ringers vs. Normal Saline for fluid resuscitation? It's been a while since I have researched it, but the last time I did, the evidence showed that there was no significant difference pre-hospital when using either for trauma related fluid replacement.

Generally, I still tend to grab the LR for trauma, given whatever vehicle I am in has it on board. I don't personally believe LR to be any 'better', but there still seems to be quite a few people (including docs) who prefer LR.

So, with that said...does any modern research show LR to be a better (or worse) choice? Anyone care to give the breakdown as to how each effects a person at the cellular level?

Thanks!

[chuckman]

Interesting that you bring this up today. I work in a pretty busy Level 1 trauma center, and I discussed this topic this week with our chief trauma resident. Pre-hospital, over the past 20ish years I have been a medic, we used both NS and LR. The literature went back and forth for many of those 20 years, with no definitive "definitely use xxxx." This week our trauma chief said "latest research" is nodding toward LR. I will ask him for citations and specific studies....since I work in a very academic place, I am certain he can give me that info pretty quickly. As a corpsman with the Marines, we used either/or, usually dependent on whatever our MO (Medical officer) or batt surgeon wanted.

[Hmac]

NS is preferred for resuscitation these days since the metabolism of lactate sets the stage for later alkalosis, and that's a bigger problem than acidosis in the post-resuscitation period.

It's all part of the old thinking that prehospital care should work to achieve normal body homeostasis. We now know that a little hypotension and a little acidosis is not only OK, but beneficial.

It's not a big deal in most situations. In a prehospital setting, your protocols should define your choice of IV fluid. If they don't (that would be odd IMHO) then NS is probably a better choice.

[BaileyMoto]

NS is preferred for resuscitation these days since the metabolism of lactate sets the stage for later alkalosis, and that's a bigger problem than acidosis in the post-resuscitation period.

It's all part of the old thinking that prehospital care should work to achieve normal body homeostasis. We now know that a little hypotension and a little acidosis is not only OK, but beneficial.

It's not a big deal in most situations. In a prehospital setting, your protocols should define your choice of IV fluid. If they don't (that would be odd IMHO) then NS is probably a better choice.

I am currently working in the middle east as a contractor and our protocols don't dictate which to use. Back in the states (I worked for both an ALS fire dept. and private ambulance) we didn't have specific protocols for either as well. Perhaps the lack of definitive studies is why no protocol has been establish (for all I know).

With that said, my superior here really shoves down our throats the idea of using LR. He is a South African medic.....and lets just say that I am a bit suspect of his claimed experiences with using LR over NS.

[BaileyMoto]

Interesting that you bring this up today. I work in a pretty busy Level 1 trauma center, and I discussed this topic this week with our chief trauma resident. Pre-hospital, over the past 20ish years I have been a medic, we used both NS and LR. The literature went back and forth for many of those 20 years, with no definitive "definitely use xxxx." This week our trauma chief said "latest research" is nodding toward LR. I will ask him for citations and specific studies....since I work in a very academic place, I am certain he can give me that info pretty quickly. As a corpsman with the Marines, we used either/or, usually dependent on whatever our MO (Medical officer) or batt surgeon wanted.

Thanks, I would appreciate any clinical studies that you could dig up.

[Hmac]

I am currently working in the middle east as a contractor and our protocols don't dictate which to use. Back in the states (I worked for both an ALS fire dept. and private ambulance) we didn't have specific protocols for either as well. Perhaps the lack of definitive studies is why no protocol has been establish (for all I know).

With that said, my superior here really shoves down our throats the idea of using LR. He is a South African medic.....and lets just say that I am a bit suspect of his claimed experiences with using LR over NS.


As Medical Director of an ALS ambulance service, IV resuscitation fluid is something I'm obligated to define, since I am solely responsible for those protocols. That said, I feel kind of ambivalent about LR vs NS. Over the last 10 years or so, studies and papers keep coming and going. We have been in a normal saline era these last few years, beginning to feel like we're trying to swing back to LR. The new thing holding that back has been the (largely theoretical) problems with calcium (new findings) on top of the already-beaten-to-death issues with metabolic alkalosis and cerebral edema in hemorrhagic shock.

[BaileyMoto]

As Medical Director of an ALS ambulance service, IV resuscitation fluid is something I'm obligated to define, since I am solely responsible for those protocols. That said, I feel kind of ambivalent about LR vs NS. Over the last 10 years or so, studies and papers keep coming and going. We have been in a normal saline era these last few years, beginning to feel like we're trying to swing back to LR. The new thing holding that back has been the (largely theoretical) problems with calcium (new findings) on top of the already-beaten-to-death issues with metabolic alkalosis and cerebral edema in hemorrhagic shock.

I assume your current protocols call for NS? If so, I'd also assume that the responding ambulances in your county/city don't carry LR what so ever?

[Bullwinkle]

You can't hang LR on a blood Y so if we give LR it's 2nd up on a large bore after a blood Y with NS in trauma.

[rsgard]

I dont know of any EMS service, fire or private, that uses anything but 0.9 NS in my area. My dept doesn't. I also work for a private service and i rarely see anything but 0.9NS on inter-facility transports, trauma or otherwise.

[Hmac]

I assume your current protocols call for NS? If so, I'd also assume that the responding ambulances in your county/city don't carry LR what so ever?

We carry some D5LR for pediatrics, but otherwise, no, we don't even have LR on the rigs.

[Limey-]

LR was used for years as the Lactate and electrolytes were 'supposed' to counter the acidotic state that results from shock.
There is no doubt that it will result in a more short term more alkalotic blood PH but at what cost??
A number of studies have shown that NS is superior in that it takes less volume to reverse shock with NS than LR. LR affects the clotting cascade negatively. LR is more prone to cause cerebral edema.
LR costs significantly more than NS with no advantage.
In multi Trauma patients requiring large transfusion and huge fluid resuscitation there are more arguments against LR than for it.

[Limey-]

BTW we carried LR for Burn Protocols...................different story.

[chuckman]

LR was used for years as the Lactate and electrolytes were 'supposed' to counter the acidotic state that results from shock.
There is no doubt that it will result in a more short term more alkalotic blood PH but at what cost??
A number of studies have shown that NS is superior in that it takes less volume to reverse shock with NS than LR. LR affects the clotting cascade negatively. LR is more prone to cause cerebral edema.
LR costs significantly more than NS with no advantage.
In multi Trauma patients requiring large transfusion and huge fluid resuscitation there are more arguments against LR than for it.

Use it, don't use it, change ad lib. That has been the official unofficial protocol for how many decades? Right now, I think ATLS is recommending LR. Anecdotally, I haven't seen a whit of difference in patient outcome between the two. But I do know neither will reverse shock, but I understand your point.

[Hmac]

The effects of NS vs LR would be highly unlikely to manifest themselves in the field or in the ER. As volume expanders for treating hypovolemia from hemorrhage, they'll be equivalent. The problems that one might theoretically see with Ringer's Lactate are going to manifest themselves in the ICU over the next few days, not pre-hospital. Anecdotally, I've never seen post-resuscitation problems that I could clearly attribute to use of one vs the other.




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[FL2011]

Came across this PDF from a EM residency program's journal club site:
Fluid Resuscitation: 0.9% Normal Saline vs Lactated Ringer's vs Albumin (http://www.emjournalclub.com/uploads/Ringers_Lactate_vs._Normal_Saline_Schott_1.2010.pdf)

[Abraxas]

I truly love this site. Where else can I get all this info in one place

[benthughes]

For trauma resuscitation I see no benefit of LR over NS as either will be used initially as volume replacements. As stated blood products shouldn't be given with LR. That in itself wins the argument in my book. In our transport environment LR is for pregnant women and NS for everyone else.

[Spike59]

As a paramedic in south Texas we dropped LR and only stock NS. It simplifies our IV selection to just 500 mls for medical situations and 1000 mls for trauma. Our medical directors felt that you did not get much benefit from LR in the pre-hospital setting. We use D25 pre-filled for peds and D50 pre-filled for adults. I agree with Abraxas that this is an outstanding site for info. EMS Paramedic for 17 years!

[parishioner]

For trauma resuscitation I see no benefit of LR over NS as either will be used initially as volume replacements. As stated blood products shouldn't be given with LR. That in itself wins the argument in my book. In our transport environment LR is for pregnant women and NS for everyone else.

Yea, I see LR given mainly in the L&D unit before a spinal or epidural due to the risk of hypotension with those procedures. Everywhere else in the hospital, its NS.

[citizensoldier16]

I'm a paramedic in NC. For the most part, 0.9% NS should be used for fluid replacement. Every ambulance in my county carries only NS. NS is good for rapid fluid replacement as well as maintenance fluid resuscitation.

LR on the other hand, should be used only in major trauma with significant blood loss, burns, or severe acidosis. LR is usually used for a short period of time because it is too high in sodium and too low in potassium compared to the homeostatic balance of the body. It can create an electrolyte imbalance if used for long periods of time (ie, more than 1000mL infused).

NS is good for treatment of dehydration if the Pt is unable to take in PO fluids fast enough or effectively enough.

In short, LR used for major trauma or burns. NS used for fluid resuscitation or maintenance fluid.

Source: Aehlert, Barbara, Paramedic Practice Today, Vol. 1

[Hmac]

I'm a paramedic in NC. For the most part, 0.9% NS should be used for fluid replacement. Every ambulance in my county carries only NS. NS is good for rapid fluid replacement as well as maintenance fluid resuscitation.

LR on the other hand, should be used only in major trauma with significant blood loss, burns, or severe acidosis. LR is usually used for a short period of time because it is too high in sodium and too low in potassium compared to the homeostatic balance of the body. It can create an electrolyte imbalance if used for long periods of time (ie, more than 1000mL infused).

NS is good for treatment of dehydration if the Pt is unable to take in PO fluids fast enough or effectively enough.

In short, LR used for major trauma or burns. NS used for fluid resuscitation or maintenance fluid.

Source: Aehlert, Barbara, Paramedic Practice Today, Vol. 1
In a prehospital setting, the concern is volume expansion. Worrying about electrolytes is way down the list and rarely of any importance for the amount of time the patient is in the field. Just hang the NS and go on to the next problem.

[sleepdr]

Unless I'm dealing with head trauma, in which case I'll prefer NS, I often hang whatever falls into my hand first.


IMHO, the issues of electrolyte, lactate, and potassium are usually eclipsed by the overwhelming acidosis from hypovolemia in trauma. It's a useful academic exercise that doesn't always translate well into actual treatment processes. Saline alone in large enough volumes can lead to acidosis. BTW, the world also won't end if you run LR and blood together. Is it optimal, no, but I know anesthesia folks have given many thousands of gallons of blood mixed with LR.

[Iraq Ninja]

With that said, my superior here really shoves down our throats the idea of using LR. He is a South African medic.....and lets just say that I am a bit suspect of his claimed experiences with using LR over NS.

Would he happen to go by the nickname of Bear and currently working out of Camp Adder? If so, I know very well and he is good to go.

I carry NS and Hextend. We are only issued NS by our company, and the main reason is related to cost. We have to get our Hextend from the military units.

There seems to be more debate CONUS than OCONUS about stuff like this, and other techniques like wound packing and tourniquet application that we take for granted.

[Gutshot John]

I used what was at hand unless contraindicated by protocol. People get too wrapped around the axle on this I think.

While certain fluids might be preferred in certain circumstances, I agree with those that say this is much ado about nothing. With very very few exceptions, if you've got a serious traumatic injury, the fluid is the least of the patient's problems as it's unlikely to make that big of a difference in the outcome.

NS is probably more universally applicable but LR seemed to be more commonly used.

[chuckman]

In the pre-hospital environment it really doesn't make much difference. Even if you pour 10 liters into a patient, it likely won't change their outcome (if someone needs 10 liters they have bigger problems). In the ICU, however, you can see the manifestations of the acidosis of prolonged NS administration. As far as giving blood with LR vs NS, I have seen a few cases of blood gelling up in the blood tubing when given with LR (which was hung by accident). I think if you are slamming in blood it likely won't make much difference as well, like giving blood through a massive transfusion protocol.

This debate won't be settled by troglodytes like us, though.

[Chris@conditionred.us]

Gents,

Keeping warmth and permissable hypotension in mind, ATLS does not draw a hard line between LR and NS.

It does describe LR as the fluid of choice for burn resuscitation, as mentioned previously.

Additionally, Hextend, once again mentioned earlier, is the fluid of choice for hypovolemia secondary to hemmorhage. Unfortunately, $ dictates a lot of what we do. One liter of Hextend, is eqivalent to more than 7 liters of Normal Saline, as it has a greater affinity to remain intravascular. Unfortunately, at $80.00 per liter we dont see too much Hextend on the street.

http://www.hospira.com/Products/Hextend.aspx

Check out the link, as they afford us with a study pertaining to this topic.

The only item of consideration would be the use of the product in the presence of Rhabdomyolysis, "with caution" as provided by the manufacturer.

Hope this helps.
Be safe.

C-

[Decon]

Of course someone would have to bring up hetastarches :D

[e1harris]

In the field I use NS for all non-trauma. That saves my LR for burns and all other trauma. I hang Hextend if a Turniquet is in place.

[Hmac]

So, you civilian EMT-P's...are these fluid resuscitation choices left to you in the field, or are you working off a set of protocols that you are obliged to follow? I realize it varies from state to state, but I'm not aware of laws in the civilian world that allow roving bands of paramedics without physician supervision.

[NinjaMedic]

It depends on the medical director. Some are very very hesitent to allow you to deviate from the written protocols, others allow medics quite a bit of lattitude to use their judgement as long as they can articulate afterwards why they did what they did.

[Hmac]

It depends on the medical director. Some are very very hesitent to allow you to deviate from the written protocols, others allow medics quite a bit of lattitude to use their judgement as long as they can articulate afterwards why they did what they did.

As I said, the laws vary from state to state, but in most states that I'm familiar with, the Medical Director is totally responsible for the way care is rendered by the EMT-P's that he has signed off on, and this is part of his State Board licensing and his liability carrier. The approach is establishing written protocols so that the MD is responsible only for the protocols, not for an individual EMT's deviation from them. Of course, since the MD is legally responsible to ensure Paramedic CME and Quality Assurance, the MD could still be held responsible for adverse outcome on THAT basis. Those are the reasons a Medical Director might be reluctant to allow deviation from protocols.

And besides, the Paramedics' job is tough enough. I have immense respect for the EMT-P's that I supervise, especially the ex-medics, but the last thing I want them doing out in the field on a snowy Minnesota back road in January is worrying about electrolyte balance, post-resuscitation pH problems, or the afterload-reduction merits of adenocard vs amiodorone.

[jklaughrey]

Use what you have on hand. Prefer NS but if all you have left is LR well by all means...

[motorwerks]

Being just an EMT I dont know all our Local EMT-P protocols.... even though I have looked over most of them. But I know I have never seen LR in any of my daily checks between 3 ambulance company's.