The battle over the superiority of resuscitation fluids is coming to a boil. Enter the Fluid Wars. Are Lactated Ringers superior to normal saline? Will LR increase a patient’s lactate? What about albumin? The Curbsiders quench the thirst for knowledge by turning to masters Dr. Pascale Khairallah (@Khairallah_P), Dr. Charlie Wray (@WrayCharles) and Dr. Joel Topf (@kidney_boy) for guidance in this special @NephMadness episode that will get your feet wet with the complicated world of fluid resuscitation.
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Written and produced by: Justin Berk, MD, Pascale Khairallah MD
NephMadness Pun Contest produced by: Hannah R Abrams MS3
Hosts: Matthew Watto MD, Paul Williams MD, Stuart Brigham MD
Edited by: Matthew Watto, MD
Guest: Pascale Khairallah MD, Charlie Wray DO, Joel Topf MD
Colloids and crystalloids are probably equally efficacious for fluid resuscitation.
Colloids are more expensive and may cause more brain injury in trauma patients.
Recent data shows Lactated Ringers (LR) may be superior to Normal Saline (NS) for fluid resuscitation based on SALT-ED and SMART trial data (less MAKE30 aka major adverse kidney events in 30 days).
High chloride content in Normal Saline can cause hyperchloremia. Consequently, the macula densa senses elevated chloride leading to vasoconstriction, which in turn can cause acute kidney injury.
The lactate in lactated ringers is benign (sodium lactate, NOT lactic acid). Checking a lactate for tissue perfusion is a proxy for lactic acidosis. The acidosis is the concern, not the lactate itself.
Patients with cirrhosis cannot metabolize lactate quickly. Thus, LR may cause a benign increase in lactate even if there is good tissue perfusion.
Normal Saline may be indicated in specific situations such as metabolic alkalosis.
LR may be more beneficial than NS in patients with hyperkalemia (even though it has added potassium). [see this post by PulmCrit for evidence review]
In 1998, a Cochrane Systematic Review showed increased mortality with albumin compared to normal saline.
A large (7,000 patients) follow-up study (SAFE trial) in 2004, showed NO change in mortality between albumin and crystalloid. However, in sub-group analysis:
Trauma patients (and traumatic brain injuries) had increased risk of death and associated brain injury with albumin use in the SAFE trial.
Septic patients showed possible benefit with albumin in the SAFE trial. BUT, a follow-up study for albumin in sepsis (ALBIOS Trial) showed albumin was confirmed to NOT be associated with improved mortality in septic patients
A Cochrane review states: “using colloids…for fluid replacement probably makes little or no difference to the number of critically ill people who die.”
Hetastarch (hydroxylethyl starch; synthetic albumin) was an attempt to have colloid fluids without the extra cost. Unfortunately, it’s been associated with increased bleeding and acute kidney injury
These trials used a composite outcome not used before: MAKE-30 aka Major Adverse Kidney Events in 30 days (death, RRT, persistent renal dysfunction at discharge).
Normal saline can lead to:
In patients with sepsis, anaerobic glycolysis will cause an increase of lactic acid.
Lactic acid = Lactate plus a Hydrogen Ion.
The hydrogen ion causes all the complications (ie the acidosis). The lactate is just the accompanying ion and is benign. Lactated ringers is Sodium Lactate and does not not contain the H+.
Kashlak Pearl: Patients with cirrhosis cannot convert lactate quickly (60% of lactate metabolism is in the liver). Thus, Lactate may go up in patients with liver disease receiving LR. BUT, this is not a sign of poor tissue perfusion. It simply reflects the slow metabolism of the benign lactate in LR. In summary, patients with a sick liver receiving LR might have a benign lactate elevation. This is not the same as lactic acidosis.
These patients need chloride.
Why give more K to a patient with elevated potassium?
Listeners will recognize the key differences among fluid resuscitation options and be familiar with recent data that guides these decisions.
After listening to this episode listeners will…
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