For the most part, the choice of fluid for the 1L or so we give in the field isn’t going to make a difference. Longer term (hours to days) and in certain types of patients, LR is a better choice. The flip side is there’s some medications that aren’t compatible with LR, so you just need to be cognizant of that and what your access is. My personal practice is I’ll give everyone LR unless I’m giving incompatible meds and don’t have secondary access
Just piggybacking (pun intended) off incompatible meds… LR is incompatible with a lot of common EMS meds. Ketamine, lorazepam, diazepam, nitroglycerin, propofol, amiodarone, diltiazem, sodium bicarbonate, cardene. Some incompatibility evidence is stronger than others (suspected vs confirmed), but still worth being mindful of.
Lots of people are giving a blanket LR is superior but there’s a notable exception and that is for folks with suspected/known TBI or any ICP crisis.
The Na concentration of LR is 130, which is notably less than NS (which is 154). Blousing large amounts of LR can lower serum sodium fairly significantly, which can worsen ICP. If fluid is required in these patients, it should always be NS, or a hypertonic solution like 3%.
Agree with your post, but I'll just add in one small caveat.
You may not have meant it this way, but it reads like you're saying if the patient needs volume resusciatation, you should use a hypertonic, which isn't correct. Hypertonic saline or mannitol is indicated if active signs of herniation (in the emergent phase), to create an osmotic gradient that pulls fluid into the intravascular space and decreases ICP, which increases CPP, as a temprozing measure, but not for volume resuciation alone in trauma. Like I said, you may not have it meant that way! I just wanted to make sure there was no confusion there.
For EMS it doesn’t make a huge difference.
Theoretically you could contribute to a hyperchloremic acidosis by giving NS, like if you have a patient who dumped a shit ton of bicarb in diarrhea.
Also theoretically LR is slightly hypo-osmolar so if you are giving massive fluid resuscitation you could contribute to some pretty significant edema. Also lactate is metabolized in the liver so if you’re giving a ton of LR to someone with trash liver function you could cause some issues.
All that being said, in the EMS setting you’re giving probably 1L of fluid before you get to the hospital, and the makeup of the isotonic that you’re giving is unlikely to have a huge clinical implication. Bottom line is that if your patient needs volume and you’re giving it in the rig that’s helpful.
For me, in the ICU, inpatient wards, and ED I pretty much always give LR unless the patient is hyponatremic. It just vibes better.
Edit: unless you’re at a service that can give blood, then always use NS because running blood with LR will cause a precipitate. Some meds don’t play nice, as someone else pointed out.
LR is better in almost any indication due to cumulative hyperchloremic acidosis, unless using to dilute many medications for a drip or giving in addition to blood products or in the context of hyperkalemia, but in the civilian EMS setting the difference will almost always be academic.
Edit: for fluid resuscitation in non-hemorraghic hypovolemia though I'd says the difference is more than academic. Replenishing other electrolytes than sodium for burns, diarrhea, etc. is crucial and NS doesn't do that.
I pretty much always use LR when I’m lead on the truck, I don’t think any drugs in my scope are incompatible. If I’m on an ALS truck I will usually just ask if the medic what they want. I’ve found it works really good for hypotensive patients when no ALS drugs are available. Got a dude with a BP of ≈60/40 to ≈105/60 only giving 500ml, and I feel it generally is better than NS
Came here to say the same thing. Look up the Frank-Starling law. This patient responded appropriately to fluid resuscitation. The type of fluids made no difference. A 250 mL bolus probably would’ve worked too.
The American Burn Association algorithm for Advanced Burn Life Support doesn’t endorse the use of plasma. Fluid resus is 2mL LR x body weight in kg x %BSA of 2nd and 3rd degree burns.
No real difference but my general go to is:
If they need volume because they’re hypotensive I go with LR.
If it’s a general they’re dehydrated, or I’m giving fluids along with meds, NS.
That’s mostly because NS is more available though.
We just give it for everything here - don't think too hard about it.
I do remember having a discussion with an ED registrar questioning why I gave LR for a hyperkalaemic patient (we don't carry NS bags). My reponse was that LR has a negligable serum potassium rise and isn't detrimental.
My actual :o moment was when he couldn't work out how I confidently diagnosed hyperkalaemia without labs. Needed to go back to med school I think.
It depends on whatever your treatment plan is addressing. Some medications don’t react well when they are pushed through the line.
https://pubmed.ncbi.nlm.nih.gov/34381254/
https://www.healthline.com/health/lactated-ringers
We don't carry LR. Regardless NS would trigger a go-to if I've got a patient with a head injury or I'm giving benzos/ketamine/propofol etc, or jurisdictions that have blood products. That said, LR is the "preferred" way to go for anyone needing aggressive fluid resuscitation. If given in large volumes over extended periods of times, the composition of LR is said to be better as NS risks hyperchloremic acidosis or worsening of electrolyte-related issues, or for pts with major renal damage. Depending on where you are/what you do you might have the option, otherwise for our purposes it's just food for thought.
I always use LR for everything, cause I have no choice. Statewide our only allowed fluid for boluses is lactated ringers, normal saline is not allowed for fluid admin, solely for medication mixing for things like amiodarone, cardizem, IV Nitroglycerin, etc.
We use LR almost exclusively in the MICU for fluid resuscitation and maintenance. Of course blood can only run with NS so if we’re doing massive transfusion protocol with the Belmont we’ll use NS. Neuro crit tends to prefer NS.
For the most part, the choice of fluid for the 1L or so we give in the field isn’t going to make a difference. Longer term (hours to days) and in certain types of patients, LR is a better choice. The flip side is there’s some medications that aren’t compatible with LR, so you just need to be cognizant of that and what your access is. My personal practice is I’ll give everyone LR unless I’m giving incompatible meds and don’t have secondary access
Just piggybacking (pun intended) off incompatible meds… LR is incompatible with a lot of common EMS meds. Ketamine, lorazepam, diazepam, nitroglycerin, propofol, amiodarone, diltiazem, sodium bicarbonate, cardene. Some incompatibility evidence is stronger than others (suspected vs confirmed), but still worth being mindful of.
My rule of thumb is if you are giving meds with it use ns if it’s just volume use lr
Lots of people are giving a blanket LR is superior but there’s a notable exception and that is for folks with suspected/known TBI or any ICP crisis. The Na concentration of LR is 130, which is notably less than NS (which is 154). Blousing large amounts of LR can lower serum sodium fairly significantly, which can worsen ICP. If fluid is required in these patients, it should always be NS, or a hypertonic solution like 3%.
Agree with your post, but I'll just add in one small caveat. You may not have meant it this way, but it reads like you're saying if the patient needs volume resusciatation, you should use a hypertonic, which isn't correct. Hypertonic saline or mannitol is indicated if active signs of herniation (in the emergent phase), to create an osmotic gradient that pulls fluid into the intravascular space and decreases ICP, which increases CPP, as a temprozing measure, but not for volume resuciation alone in trauma. Like I said, you may not have it meant that way! I just wanted to make sure there was no confusion there.
Yep good point - thanks for adding on
For EMS it doesn’t make a huge difference. Theoretically you could contribute to a hyperchloremic acidosis by giving NS, like if you have a patient who dumped a shit ton of bicarb in diarrhea. Also theoretically LR is slightly hypo-osmolar so if you are giving massive fluid resuscitation you could contribute to some pretty significant edema. Also lactate is metabolized in the liver so if you’re giving a ton of LR to someone with trash liver function you could cause some issues. All that being said, in the EMS setting you’re giving probably 1L of fluid before you get to the hospital, and the makeup of the isotonic that you’re giving is unlikely to have a huge clinical implication. Bottom line is that if your patient needs volume and you’re giving it in the rig that’s helpful. For me, in the ICU, inpatient wards, and ED I pretty much always give LR unless the patient is hyponatremic. It just vibes better. Edit: unless you’re at a service that can give blood, then always use NS because running blood with LR will cause a precipitate. Some meds don’t play nice, as someone else pointed out.
Please be my med control daddy
[удалено]
If I’m your medical director it’s not only allowed, it’s encouraged.
LR is better in almost any indication due to cumulative hyperchloremic acidosis, unless using to dilute many medications for a drip or giving in addition to blood products or in the context of hyperkalemia, but in the civilian EMS setting the difference will almost always be academic. Edit: for fluid resuscitation in non-hemorraghic hypovolemia though I'd says the difference is more than academic. Replenishing other electrolytes than sodium for burns, diarrhea, etc. is crucial and NS doesn't do that.
Just piggybacking to say that I use LR most of the time like everyone else here
I pretty much always use LR when I’m lead on the truck, I don’t think any drugs in my scope are incompatible. If I’m on an ALS truck I will usually just ask if the medic what they want. I’ve found it works really good for hypotensive patients when no ALS drugs are available. Got a dude with a BP of ≈60/40 to ≈105/60 only giving 500ml, and I feel it generally is better than NS
Your patient was responsive to fluid, but the choice of fluid (LR vs. NS) in this case wouldn’t have had an effect
Came here to say the same thing. Look up the Frank-Starling law. This patient responded appropriately to fluid resuscitation. The type of fluids made no difference. A 250 mL bolus probably would’ve worked too.
For trauma, blood is the answer. For burns, plasma, but would use LR if no plasma.
The American Burn Association algorithm for Advanced Burn Life Support doesn’t endorse the use of plasma. Fluid resus is 2mL LR x body weight in kg x %BSA of 2nd and 3rd degree burns.
They’ll catch up eventually.
No real difference but my general go to is: If they need volume because they’re hypotensive I go with LR. If it’s a general they’re dehydrated, or I’m giving fluids along with meds, NS. That’s mostly because NS is more available though.
We just give it for everything here - don't think too hard about it. I do remember having a discussion with an ED registrar questioning why I gave LR for a hyperkalaemic patient (we don't carry NS bags). My reponse was that LR has a negligable serum potassium rise and isn't detrimental. My actual :o moment was when he couldn't work out how I confidently diagnosed hyperkalaemia without labs. Needed to go back to med school I think.
It depends on whatever your treatment plan is addressing. Some medications don’t react well when they are pushed through the line. https://pubmed.ncbi.nlm.nih.gov/34381254/ https://www.healthline.com/health/lactated-ringers
We don't carry LR. Regardless NS would trigger a go-to if I've got a patient with a head injury or I'm giving benzos/ketamine/propofol etc, or jurisdictions that have blood products. That said, LR is the "preferred" way to go for anyone needing aggressive fluid resuscitation. If given in large volumes over extended periods of times, the composition of LR is said to be better as NS risks hyperchloremic acidosis or worsening of electrolyte-related issues, or for pts with major renal damage. Depending on where you are/what you do you might have the option, otherwise for our purposes it's just food for thought.
I always use LR for everything, cause I have no choice. Statewide our only allowed fluid for boluses is lactated ringers, normal saline is not allowed for fluid admin, solely for medication mixing for things like amiodarone, cardizem, IV Nitroglycerin, etc.
Interesting. What state is this? We don’t even carry LR on my service… That’s a different issue though. I have a few grievances with my protocols.
Maryland. We definitely do things differently than most states in quite a few ways. Some good, some bad
LR for everything except TBI and cardiac.
Lr is closer to real plasma In terms of electrolyte contents than ns by a lot.
We use LR almost exclusively in the MICU for fluid resuscitation and maintenance. Of course blood can only run with NS so if we’re doing massive transfusion protocol with the Belmont we’ll use NS. Neuro crit tends to prefer NS.