What do you prefer - LR or NS?

**BaileyMoto** · 07-03-10, 04:58

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** · 07-03-10, 09:17

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** · 07-03-10, 09:20

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** · 07-03-10, 09:26

Originally Posted by 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.

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** · 07-03-10, 09:30

Originally Posted by 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.

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

**Hmac** · 07-03-10, 10:01

Originally Posted by BaileyMoto

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** · 07-03-10, 10:13

Originally Posted by Hmac

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** · 07-03-10, 11:45

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** · 07-03-10, 11:48

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.