Lactated Ringers for Fluid Resus..Friend or Foe..!?!?!

[Ace844]

Hi All,

I saw this and was curious what you thought and whether you had seen any evidence of this in your practice...YES, I know the study was done on Pigs!!!! :roll:

Endothelial Dysfunction After Lactated Ringer's Solution Resuscitation for Hemorrhagic Shock.

Journal of Trauma-Injury Infection & Critical Care. 59(2):284-290, August 2005.

Savage, Stephanie A.; Fitzpatrick, Colleen M.; Kashyap, Vikram S. MD ++; Clouse, W Darrin; Kerby, Jeffrey D. MD, PhD

Abstract:

Background: Endothelial dysfunction is presumed to occur after hemorrhagic shock and resuscitation. This study uses a novel large-animal model to evaluate the effects of diverse resuscitation regimens on endothelial function.

Methods: Twenty-seven adult domestic pigs (Sus scrofa) were used in this study. Control pigs (n = 3) underwent instrumentation alone. The remaining pigs experienced controlled hemorrhagic shock to a mean arterial blood pressure of 30 +/- 5 mm Hg for 45 minutes. Pigs were resuscitated to their baseline mean arterial blood pressure +/-5 mm Hg with either shed blood (SB; n = 8), lactated Ringers solution (40 mL/kg) followed by shed blood (LRSB; n = 8), or lactated Ringers solution alone (LR; n = 8). At baseline, 1 and 4 hours after resuscitation, acetylcholine (5, 10, and 15 [mu]g/min) was infused into the proximal iliac artery to measure endothelial dependent relaxation (EDR). Sodium nitroprusside was infused to determine endothelial independent relaxation at the end of the study to insure smooth muscle vasomotor integrity. External iliac artery luminal diameter was measured using motion-mode ultrasonography. Statistical analysis was performed using repeated-measures analysis of variance with Tukey's post-hoc analysis.

Results: All pigs survived the experiment. Pigs required ninefold more resuscitation with LR (370.58 +/- 29 mL/kg) versus SB (41.45 +/- 3.5 mL/kg) or LRSB (76.4 +/- 1.1 mL/kg) (p < 0.05). EDR for LR pigs 1 hour after initiation of resuscitation (R1) was 70.4 +/- 14.4% compared with 94.2 +/- 13.4% for SB and 106.1 +/- 8.2% for LRSB (p < 0.05). At 4 hours after resuscitation (R4), systolic luminal diameters were larger in the SB (0.45 +/- 0.01 cm) and LRSB (0.51 +/- 0.02 cm) groups compared with LR (0.41 +/- 0.03 cm) (LRSB versus LR; p = 0.01). At R4, EDR for the LR group was 78.3 +/- 10.7% compared with SB (101.4 +/- 8.3%) and LRSB (106.4 +/- 7.4%) (p < 0.05). Infusion of sodium nitroprusside confirmed integrity of smooth muscle vasorelaxation. Analysis of serum nitric oxide levels revealed decreased values after resuscitation with LR (9.44 +/- 0.76 mol/L) compared with SB (26.3 +/- 7.8 mol/L) and LRSB (16.3 +/- 1.0 mol/L) (p = not significant).

Conclusion: This is the first description of a large-animal model to evaluate EDR after hemorrhagic shock. Resuscitation with LR requires significantly larger volumes than SB or LRSB. LR resuscitation leads to endothelial dysfunction, as determined by decreased EDR, versus SB or LRSB. Resuscitation with blood products may preserve nitric oxide bioactivity when compared with crystalloid resuscitation in the setting of hemorrhagic shock.

out here,

Ace844

[AZCEP]

Since the use of LR by itself requires larger volumes to acheive fluid resuscitation, can we then assume the use of Saline would cause the same dysfunction of the endothelium. It seems that using non-oxygen carrying substances is on it's way out of the mainstream of clinical practice anyway. But until the technology trickles down, it is all we have.

[Dustdevil]

Sure are a lot of people out there doing lame, pointless studies. I think they just like seeing their names in print. They want "credits" to pad their resumes. This study tells us nothing we didn't know 30 years ago.

What next, a study to tell us the sky is blue? :roll:

[Ridryder 911]

Ditto, what Dustdevil said. This is similar study they have been doing to display shock syndromes and the effectiveness of fluid resuscitation. This method has been shown to be flawed and I really do not know why they they would pursue such a study?

RL or LR or Hartmans solution has been utilized because of it components and the lactate in the fluid. Some even prefer the D5RL with the dextrose needed in metabolism of shock.

Be safe,

R/R 911

[fireresque51]

Some of the studies my department has looked at say the same thing. But LR being a large mollecule protine even though it is isotonic out side the body , once in it acts a a hypertonic solution due the the size of the protine mollecule, some say great it pulls more fluid, but that is bad because it decreases the amout if intracellular fluid and causes the build up of lasctic acid. Were NS is isotonic across the board and does not pull from intracellular there for it is better than LR in that since, but as we are all aware, only blood, and blood substitues like hemopure and the other in testing will reallyl benifit the pt. As long as we are having to do 3 to 1 repalcement we will never solve the problem.

Untill then my department is using only NS in trauma, LR is used only in burns and OB.

[Off Label]

In trauma, too much of any crystalloid is bad... it causes hemodilution, dilutional coagulopathy, raises blood pressure which breaks clots etc.

 

This is not the thinking of 30 years ago and anecdotal evidence isn't good enough. We really don't learn this stuff unless we study it. War time accelerates our understanding, but without formal investigations, we have no basis for what we can say with confidence.