NS - going the way of MAST pants?

[MedicNorth]

At a recent convention I had the opportunity to listen to two different sessions on IV therapy. Both were very well done, and informative, but had very different messages.

The first extolled the value of traditional Normal Saline in various situations, from Ketoacidosis to trauma resuscitation. The other painted NS as an invention of the devil, with no redeeming qualities other than that it is liquid. He cited studies that seem to show that NS is not as effective as other alternatives such as Plasma-Lyte, and in some cases is actually harmful, causing kidney damage, exacerbating ketoacidosis and hyperchloremia, among other potentially devastating effects. His expectation was that NS would be gone from our kits very soon, and tomorrow was too late.

Does anybody have any experience with alternative solutions who could add information to this? There is a fair amount of research out there, but much of it is in very small studies.

 

[1EMT-P]

 

 

I don't see either LR or NS being removed from our kits anytime soon & here is why. We are familiar with LR & NS & we know how they work, but Plasma-Lyte is fairly new & we don't really know how it works. In addition there is also the issue of cost, LR & NS cost much less than Plasma-Lyte. I have enclosed the link to an article that you may find interesting.http://www.pulmcrit.org/2015/01/three-myths-about-plasmalyte-normosol.html

 

Cheers,

1EMT-P

[hertzvanrental]

There aren't many patients that really benefit from prehospital iv fluid. Trauma for a Start, particularly penetrating trauma. The first clot is the best so why risk blowing it of with Salty water! IV TXA, pelvic binder and traction splints for femoral fractures and get them into surgery. Also think about how permissive hypotension may benefit certain too. DKA,  do you  really want to fill patients up quick?  No.  I'm not saying IV fluid doesn't have its place just not in the excess that it's currently used. Here in the UK we've eased right  off. However my last patient today had some Ns, morphine, ondansetron for their acute pancreatitis!

 

 

[chbare]

Just to clarify, are you saying DKA patients should not routinely receive initial blouses of fluid?

[MedicNorth]

There are a lot of studies and opinion papers that seem to state that NS therapy for DKA patients can frequently exacerbate issues: worsening hyperchloremia which can cause severe kidney damage, increasing edema, unbalancing electrolyte concentrations, etc. More studies indicate that what we in North America consider to be routine prehospital treatment with our favourite boluses are not as effective as we would hope either.

I am on the fence with this one, still reading all the research I can find, but I know that we use much more NS here than the rest of the EMS world does.

[chbare]

I've read a couple of opinions and one can be referenced here: http://www.bmj.com/rapid-response/2011/11/01/hartmann’s-solution-and-09-saline-are-both-unsuitable-severe-dka

Unfortunately, the author references many sources that do not specifically consider DKA. I will also refrain from a strong ion discussion but I'm not convinced that a SID approach is superior and clinically more useful than standard approaches. 

 

Ive seen modest studies that compare NS and LR in DKA patients. One such abstract can be referenced here: http://www.ncbi.nlm.nih.gov/m/pubmed/22109683/

I would love a reasonable evidence based approach but I'm not really compelled to say NS volume expansion in a prehospital setting involving DKA is harmful. I'm willing to change my mind however. 

[Off Label]

This was far more of an issue when we gave a lot more crystalloid for all kinds of things. It only really matters now in a couple of settings. If giving less that 1.5 liters or so of crystalloid, the fluid doesn't matter. It's an issue when giving several liters over a couple of hours. It that situation, Plasmalyte/Normosol is superior to LR which is superior to NS. The reason being that acidosis is far easier to manage. The fall in pH isn't as profound with Plas/Norm as it is with LR in situations where there is a lot of blood loss and clamping and unclamping of the aorta, iliacs etc in an OR setting.

That said, again, we don't give a lot of crystalloid anymore, so the argument really doesn't apply in most settings.

[ERDoc]

Our trauma service likes trauma pts to receive normasol or LR.  Even in our sepsis guidelines, the max NS is 2L, after that we switch to LR or start pressors.

[Off Label]

Not to put too fine a point on it.... but.... that we're still using NS at all is astounding. It was only used in war time in the mid 20th century because it was cheap, and it's anything but 'normal'. Giving it to someone who is already acidotic when something like plasmalyte or normosol (the same things) are lying around somewhere in the hospital would seem to result in chasing our tails with regard to correction of acid/base balance.

Edited December 30, 2015 by Off Label