LR

[Alan Baker]

Resuscitation With Normal Saline (NS) vs. Lactated Ringers (LR) Modulates Hypercoagulability and Leads to Increased Blood Loss in an Uncontrolled Hemorrhagic Shock Swine Model. 

Original Articles 
Journal of Trauma-Injury Infection & Critical Care. 61(1):57-65, July 2006.
Kiraly, Laszlo N. MD; Differding, Jerome A. MS; Enomoto, T Miko MD; Sawai, Rebecca S. MD; Muller, Patrick J. MS; Diggs, Brian PhD; Tieu, Brandon H. MD; Englehart, Michael S. MD; Underwood, Samantha MS; Wiesberg, Tracy T. MD; Schreiber, Martin A. MD 
Abstract: 
Background: Lactated ringers (LR) and normal saline (NS) are used interchangeably in many trauma centers. The purpose of this study was to compare the effects of LR and NS on coagulation in an uncontrolled hemorrhagic swine model. We hypothesized resuscitation with LR would produce hypercoagulability. 
Methods: There were 20 anesthetized swine (35 +/- 3 kg) that underwent central venous and arterial catheterization, celiotomy, and splenectomy. After splenectomy blinded study fluid equal to 3 mL per gram of splenic weight was administered. A grade V liver injury was made and animals bled without resuscitation for 30 minutes. Animals were resuscitated with the respective study fluid to, and maintained, at the preinjury MAP until study end. Prothrombin Time (PT), Partial Thromboplastin Time (PTT), and fibrinogen were collected at baseline (0') and study end (120'). Thrombelastography was performed at 0'and postinjury at 30', 60', 90', and 120'. 
Results: There were no significant baseline group differences in R value, PT, PTT, and fibrinogen. There was no significant difference between baseline and 30 minutes R value with NS (p = 0.17). There was a significant R value reduction from baseline to 30 minutes with LR (p = 0.02). At 60 minutes, R value (p = 0.002) was shorter while alpha angle, maximum amplitude, and clotting index were higher (p < 0.05) in the LR versus the NS group. R value, PT, and PTT were significantly decreased at study end in the LR group compared with the NS group (p < 0.05). Overall blood loss was significantly higher in the NS versus LR group (p = 0.009). 
Conclusions: This data indicates that resuscitation with LR leads to greater hypercoagulability and less blood loss than resuscitation with NS in uncontrolled hemorrhagic shock. 
(C) 2006 Lippincott Williams & Wilkins, Inc. 


http://www.anesthesia-analgesia.org/cgi/reprint/88/5/999.pdf

Normal Saline Versus Lactated Ringer's Solution for Intraoperative Fluid Managemnt in Patients Undergoing Abdominal Aortic Aneurysm Repair: An Outcome Study 
Source: Waters et al. Anesth Analg 2001; 93: 817-22 
Reviewer:  R. Prasad, MD 
Summary: 
NS group developed hyperchloremic metabolic acidosis 
NS group got more intraop bicarb, platelets. 
No diff in postop outcomes. 
More blood products (including FFP, platlets, PRBC, albumin) given to NS group 
Comments: 
Need larger numbers to look at individual blood product requirements more closely 
Wonder about the conclusion re: sum of all blood products ... if hetastarch (in NS or LR) were used instead of albumin, would there still be a significant difference? 
Is a temporary hyperchloremic metabolic acidosis really much of a problem? 
Methods: 
66 open AAA, standard anesthetic (iso/fent/cisatracurium, thoracic epidural bolused with MSO4 and bupiv/fent/epi gtt started after unclamping, when stable) 
Randomized to LR or NS as predominant fluid (started on arrival to OR, ended on arrival to ICU) 
Exclusions: h/o abnl renal fnct, abnl BUN or Cr or Na values, acid-base abnormalities 
PRBC if Hgb<10; FFP, platelets given when evidence of microvascular bleeding, and point-of-care PT/PTT measurements 
Std monitors, a-line, CVC, PAC at anesthesiologists' discretion. Crystalloid given to keep PAOP or CVP within 10% of baseline. Coloid restricted to periods of rapid blood loss. Bicarb only if base balance < -5 ( [body weight kg x base deficit x 0.3] /2). 
Sample size based on changes in BE in prelim study of 25 pts. With 33 pts/group, there is 90% power to detect difference in BE of 5 mEq/L or more from baseline with p>0.05, assuming the std dev of change from baseline was ~3 mEq/L (from prelim study). Posthoc analysis indicated they had 90% power to detect 10% change in values of continuous outcome measures. 
Results: 
33 pts per group. 
No differences in demographic data or incidence of chronic disease 
except HTN (NS 85%, LR 58%) 
however, no diff in number of pts being medicated for HTN 
Similar AAA locations, lines (CVC v. PAC) 
Volume crystalloids, EBL, PRBC, FFP, albumin similar (though NS 500ml albumin vs. LR 0 - not significant) 
NS: 
UOP more (1200ml vs. 975ml) 
got more bicarb intraop (40ml vs. 4ml) 
more platelets (552ml vs. 421ml) 
greater overall blood product exposure (including PRBC, FFP, plt, albumin) 
Similar postop complications, vent time, ICU time, hosp stay 
Discussion: 
Post hoc power calculation suggests sample size was adequate to detect 10% difference between groups. 
Acidosis after NS resulted in more bicarb administration intraop, but no diff in ICU bicarb requirements - suggests NS-related changes were transient. 
Larger UOP in NS may be b/c they received average of 500ml more crystalloid, 1500ml more total fluid (although differences in each were not significantly different). Interpretation complicated by use of dopamine during surgery. 
No diff in EBL, but fewer blood products given in LR group (plts and FFP, 


It would be interesting to hear the rationale from those that made the decisions.

Good luck and may God protect you.

Hey


----- Original Message ----
From: Ronald Bolen <bolen001 at mc.duke.edu>
To: flightmed at flightweb.com
Sent: Wednesday, August 29, 2007 2:03:19 PM
Subject: LR


Hello all,

I have a practice question. We (the military) have recently changed our 
teachings based on experiences in Iraq in relations to the resuscitation 
of trauma patients. One of the big ones is the use of LR. For En Route 
Care (Army & Navy transport) we have changed to using Saline because of 
the label on LR where it states "not to be used in the presence of 
acidosis". Does anyone know of any literature for or against the use of LR 
based on the lactate present in LR? I cannot find anything in my 
Literature searches.

Thanks,

Ron

Ron Bolen, RN, BSN, CEN, CFRN, CCRN, NREMT-P
Clinical Nurse Educator
Education Services
Duke University Health System
919-684-2750 (Office)
919-970-7320 (Pager)


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