Consider LACTATED ringer's over normal saline for fluid resuscitation

Lean toward Lactated Ringer's (LR) for fluid resuscitation. Its cost is similar to saline, and less than other balanced fluids....
Abdelwahab Ward, BS Pharm, PharmD

As a hospital pharmacist, you'll hear debate over using Lactated Ringer's or other balanced fluids instead of normal saline for fluid resuscitation. Balanced fluids, such as Lactated Ringer's (LR) or Plasma-Lyte, are touted as having electrolyte content similar to plasma, while normal saline has higher levels of chloride. The concern is that large volumes of normal saline can lead to hyperchloremic acidosis, which is associated with acute kidney injury.

Previous evidence comparing normal saline with balanced fluids suggests there isn't a difference in clinical outcomes. Now new data suggest that using balanced fluids (LR) may prevent one case of acute kidney injury for every 91 ICU patients treated or every 111 non-ICU patients compared to normal saline. But be aware, these data have limitations. For example, it's a single-center study that didn't control for factors such as the amount of fluid prescribed.

Lean toward Lactated Ringer's (LR) for fluid resuscitation. Its cost is similar to saline, and less than other balanced fluids. But consider electrolyte differences. For example, steer away from Lactated Ringer's in traumatic brain or other neurological injuries, since its sodium content is lower. In these patients, consider normal saline or balanced fluids with more sodium, such as Isolyte. Also avoid LR in patients with hypercalcemia, due to calcium content.

Also think about compatibility issues with electrolytes in balanced fluids. For example, avoid infusing Lactated Ringer's with ceftriaxone in newborns even through separate lines due to precipitation risk. Ceftriaxone and LR can be used together in patients older than 28 days as long as they are infused separately and lines are properly flushed between infusions.

In patients with renal or hepatic impairment Use of balanced fluids in patients with severe liver impairment or existing alkalosis may lead to or worsen alkalosis as the metabolism of the buffers may be impaired (e.g., acetate, gluconate, lactate). Consider limiting use of large volumes of normal saline in patients with impaired renal function, especially with concomitant heart failure, due to risk of sodium retention.

For hyperkalemia. Experts suggest that the small amounts of potassium in balanced fluids are unlikely to lead to hyperkalemia, even in patients with renal insufficiency. Even small amounts of potassium may not be desirable in patients with severe hyperkalemia (e.g., serum potassium > 6 mEq/L) due to potential for arrhythmias. Normal saline may be preferred in patients with severe hyperkalemia (e.g., potassium > 6 mEq/L) as normal saline does not contain any potassium.

References

  • Self WH, Semler MW, Wanderer JP, Wang L, Byrne DW, Collins SP, Slovis CM, Lindsell CJ, Ehrenfeld JM, Siew ED, Shaw AD, Bernard GR, Rice TW; SALT-ED Investigators. Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med. 2018 Mar 1;378(9):819-828. Available at: https://pubmed.ncbi.nlm.nih.gov/29485926

    Young P, Bailey M, Beasley R, Henderson S, Mackle D, McArthur C, McGuinness S, Mehrtens J, Myburgh J, Psirides A, Reddy S, Bellomo R; SPLIT Investigators; ANZICS CTG. Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit: The SPLIT Randomized Clinical Trial. JAMA. 2015 Oct 27;314(16):1701-10. Available at: https://pubmed.ncbi.nlm.nih.gov/26444692

    Jaynes MP, Murphy CV, Ali N, et al. Association between chloride content of intravenous fluids and acute kidney injury in critically ill medical patients with sepsis. J Crit Care 2018;44:363-7. Available at: https://pubmed.ncbi.nlm.nih.gov/29288964

Abdelwahab Ward, BS Pharm, PharmD