# IV Solutions



## ffemt8978 (Jun 22, 2004)

I've noticed a trend in the hospital and prehospital environment of everyone going to using just 0.9% Normal Saline for IV solution.  We seem to be getting away from D5W and Lactated Ringers (or Ringers Lactate).

Anyone know why we are doing this?  I mean, D5W and LR had their place depending upon what you wanted the IV (and drugs pushed IV) to do.


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## ResTech (Jun 22, 2004)

The fluid of choice for the pre-hospital environment (more so for fluid replacement in the trauma patient) has been up for debate for some time. Some docs prefer Normal Saline(NSS) and others live by Lactated Ringers(LR). The primary thing here that get's considered is the the buffering capability of LR versus NSS which deals with acidosis. 

NSS is just that, NSS (.9%NCL) without anything else added and does not maintain the balance of electrolytes and promotes acidosis with prolonged administration. LR on the other hand consist of "sodium chloride, potassium chloride, calcium chloride for ionic balance, manitol to control osmotic pressure, and a phosphate buffer and HCl to adjust pH". LR tends to keep the body's chemistry more within normal limits. 

But pre-hospital, either fluid is acceptable given the short period of time the patient is in the field and acidosis usualll does not create any ill effect and can be easily corrected. To answer your question specifically though I think alot of it has to do with cost. It is cheaper to carry a single IV fluid versus two and the same effect can be achieved. 

Here is an excerpt from an article that appeared in EMS magazine that describes alittle more the difference and debate of using the two IV fluids in the field:

"Both fluids are generally considered to be isotonic fluids that stay in the vascular space longer than hypotonic fluids like dextrose and water.

The argument for lactated Ringer's is that it is an electrolytically balanced fluid, while large infusions of saline may produce acidosis in patients, complicating their recovery. Proponents of saline would argue that LR is not compatible with blood transfusions and that the acidosis can be corrected. Those using Ringer's argue that while, theoretically, the calcium may present some concerns over clotting, it is not incompatible with blood transfusions. Using saline for trauma patients also allows EMS units to carry a single IV fluid".


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## ffemt8978 (Jun 23, 2004)

ResTech,

Thanks for posting the excerpts.

I may have mentioned that I live in a very rural area, and it is approximately a one hour transport to ANY hospital.  We are also limited to pushing 2 liters of IV fluid in the field, without contacting medical control and getting permission for any more.

I know 0.9% NS is the cheaper of the three fluids (maybe that is why so many agencies want to carry it only), but I tend to agree with the electrolyte argument.


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## ResTech (Jun 23, 2004)

No problemo.... I agree cost is probably a driving force especially combined with the physiological equivalence of both fluids when used pre-hospital during a short time period. Alot of things in EMS seem to be cost driven though . All the ALS services in my area still carry both fluid types. 

Two liters of fluid is pretty standard given the normal infusion dose of 20cc/kg (20cc x 100kg(220lb)=2000cc). Unless your way out in the boonies most of the time you will not have the time to infuse two liters of fluid.


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## ffemt8978 (Jun 23, 2004)

> _Originally posted by ResTech_@Jun 22 2004, 09:18 PM
> * Two liters of fluid is pretty standard given the normal infusion dose of 20cc/kg (20cc x 100kg(220lb)=2000cc). Unless your way out in the boonies most of the time you will not have the time to infuse two liters of fluid. *


 Turn left at the boonies and go for a really long way.  Then keep going some more, and you'll find us.


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## ResTech (Jun 23, 2004)

10-4.... gotcha ...lol


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## ffemt8978 (Jun 23, 2004)

Getting back on point, let's talk about the trauma patient.  We see a lot of pretty serious trauma here.  I've been on only two accidents that did not have a fatality.  Given our extended transport, even with an ALS intercept or med flight, the Golden Hour is going to be completely shot by the time they get to the hospital (much less the OR).  

I know that if you give more than 2000 cc, you're essentially making pink lemonade.  My point is that with LR, you do a lot more good for the blood chemistry than with NS.  Also, since we're in the middle of the desert, we see a lot more dehydration (even in our trauma patients).  LR would certainly help restoring their blood chemistry and replacing lost electrolytes.


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## rescuecpt (Jun 24, 2004)

Do you have a protocol for treating dehydration?  In New York State we do not.  For trauma we can push 3 litres NS before calling Medical Control.   The theory is just to replace lost volume - deciding which fluid to use and why would only waste time and leave the heart pumping away for nothing for that much longer.  At least, that's my interpretation.


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## ffemt8978 (Jun 25, 2004)

> _Originally posted by rescuelt_@Jun 24 2004, 10:13 AM
> * Do you have a protocol for treating dehydration?  In New York State we do not.  For trauma we can push 3 litres NS before calling Medical Control.   The theory is just to replace lost volume - deciding which fluid to use and why would only waste time and leave the heart pumping away for nothing for that much longer.  At least, that's my interpretation.    *


 No, we don't.  Got one for Epitaxis, though.  :blink: 

Also, our protocols also only allow us to give 15 lpm via NRB.  Can't dial it down in the medical patient that isn't deflating the NRB bag and doesn't need 15 lpm.


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## rescuecpt (Jun 25, 2004)

Our protocol is 12 - 15lpm non-rebreather, 4-6lpm for a nebulizer, and 2-6lpm for a nasal cannula only if the patient does not tolerate the non-rebreather.

Then there's my personal favorite, the blow-by teddybear for peds.  It's this yellow teddybear, the tubing goes in its back, and the O2 comes out of its tummy.  All you have to do is play with it close to the child or convince them to give it kisses and you're all set.


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## ffemt8978 (Jun 25, 2004)

Okay, let's talk about the cardiac patient, where the choice is between LR, NS, and D5W.

LR - Would help correcting the respiratory and metabolic acidosis that happens, but being isotonic, is not as good for administering drugs.  Also, certain drugs can't be pushed with LR.

NS - Can push almost any drug, but doesn't help with acidosis.

D5W - Being a hypotonic solution, it travels into the cells much easier, and can bring the drugs to the cellular level much faster.  Does nothing for correcting acidosis, though.

Which one would you prefer on a cardiac arrest?


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## rescuecpt (Jun 25, 2004)

What if you have drugs to correct acidosis?  Then it appears NS is the best answer.


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## ffemt8978 (Jun 25, 2004)

> _Originally posted by rescuelt_@Jun 25 2004, 08:02 AM
> * What if you have drugs to correct acidosis?  Then it appears NS is the best answer. *


 If you're allowed to push drugs.


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## rescuecpt (Jun 25, 2004)

I forgot about that - Basics can't push drugs in NY State.  They also can't start IVs.


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## ResTech (Jun 25, 2004)

Some good questions posed...here is a little primer (best as I can remember) on acidosis and treatment. 

As far as acidosis is concerned in the field the primary treatment has shifted away sodium bicarb to pure delivery of good ventilation. The reason for this is that in the field, it is a guessing game as to the level of acidosis present since obviously we have no capability to obtain blood chemistry results and studies show no clear improvement in outcome when sodium bicarb is given. 

Even with ACLS standards in an arrest situation sodium bicarb for control of acidosis is pretty far down the list and most of the time never get's administered. But in an arrest of extended downtime I've seen it given basicly just because everything else was done and it "may" be useful. Way back in the day sodium bicarb used to be one of the first drugs given based on the rationale of needing to correct the acidosis pharmacologically versus with just ventilation in the field.

Most often, acidosis is the result of absent or ineffective ventilation which causes a shift from aerobic to anerobic respiration - the by-product of which is lactic acid/CO2. By securing a good airway and ventilating with high flow O2, gas exchange is then able to take place and the pCO2 will start to come down to normal or near normal levels. This is where pre-hospital capnography comes into great use for evaluating how effective ventilation is being delivered. In fact, PA protocol states that ventilation is to be used to control any suspected acidosis.  

Another common cause of metabolic acidosis is diabetic ketoacidosis(DKA) from hyperglycemia - the primary treatment pre-hospital is a fluid bolus of NSS. So here you can sort of see that NSS does not promote acidosis until given in high volumes such as 2-3 liters and the body is not able to adjust itself to maintain the normal balance which would be the case in severe traumatic injury.    

The IV solution used in an arrest situation really has no effect on acidosis. Acidosis is the least of the patients (and provider's) worries when in arrest as we all know.


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## ffemt8978 (Jun 27, 2004)

Excellent post!

I forgot about how hard it would be to maintain that 20:1 bicarbonate buffer in the field.  Unfortunately, we don't use End Tidal CO2 monitors on our patients since we don't intubate them.  Proper ventilation does seem to be the way to go to correct acidosis.


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## medicdan (Sep 10, 2013)

ffemt8978 said:


> Okay, let's talk about the cardiac patient, where the choice is between LR, NS, and D5W.
> 
> LR - Would help correcting the respiratory and metabolic acidosis that happens, but being isotonic, is not as good for administering drugs.  Also, certain drugs can't be pushed with LR.
> 
> ...


        Accidental post


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## Akulahawk (Sep 10, 2013)

ffemt8978 said:


> Okay, let's talk about the cardiac patient, where the choice is between LR, NS, and D5W.
> 
> LR - Would help correcting the respiratory and metabolic acidosis that happens, but being isotonic, is not as good for administering drugs.  Also, certain drugs can't be pushed with LR.
> 
> ...


I would prefer NS because it's compatible with basically any drug that I would have to push through the line. LR would be my 2nd choice. D5W would be OK but it doesn't stay in the vasculature very long, once the dextrose is metabolized. In an arrest, while the dextrose might not metabolize, if ROSC is achieved, it will go away pretty quickly, and then the water left behind will quickly diffuse into the cells. NS and LR will stay in the vasculature longer and other fluids can be chosen for rehydration if that becomes necessary. 

Just my thoughts at the moment...


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## chaz90 (Sep 10, 2013)

Holy necro posts Batman! Some interesting material here though.


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## PotatoMedic (Sep 10, 2013)

Very interesting necro post too!  Glad it came back from the dead.


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## TheLocalMedic (Sep 11, 2013)

As far as I'm concerned, there isn't much of a difference between LR and NS for EMS providers.  Even with long transport times (and I hear ya, I worked in a system where we had >1 hr transports) the acidosis factor really doesn't come into play.  If a patient needs a full two liters en route then they're really really sick, and probably the last thing I'm worried about is their acid-base balance.  Try to maintain a SBP of 90 mmHg, giving tons of fluids (especially in traumas)  just leads to you diluting their existing volume.  Even severe dehydration or heat stroke cases don't really benefit much more from one than the other.


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## EMT B (Sep 13, 2013)

forgive me if im not thinking clearly or if ive got my stuff bass ackwards, but how is NS going to cause acidosis over a long period of time? its an isotonic solution...

also wouldn't LR be a better choice for your traumas because of the volume expanding properties of the electrolyte solution?


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## VFlutter (Sep 13, 2013)

Saline Induced Hyperchloremic Metabolic Acidosis


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## Carlos Danger (Sep 13, 2013)

EMT B said:


> forgive me if im not thinking clearly or if ive got my stuff bass ackwards, but how is NS going to cause acidosis over a long period of time? its an isotonic solution...



Hyperchloremia with large volume infusions (like 8+ liters).



EMT B said:


> also wouldn't LR be a better choice for your traumas because of the volume expanding properties of the electrolyte solution?



LR expands volume no more than NS. Neither exert osmotic pressure, and neither remain in the vascular space for very long.

LR is considered by many to be a better choice because large volumes of it are thought less likely to promote acidosis than large volumes of NS.


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## Aprz (Sep 13, 2013)

EMT B said:


> forgive me if im not thinking clearly or if ive got my stuff bass ackwards, but how is NS going to cause acidosis over a long period of time? its an isotonic solution...
> 
> also wouldn't LR be a better choice for your traumas because of the volume expanding properties of the electrolyte solution?


Isotonic just means the osmotic pressure is similar to blood. Hypertonic, blood is drawn outta cells into vascular space. Hypotonic, fluids go into the swells causing it swell.

Even though there is equal amount of Na+ and Cl- at first, the Na+ is depleted/gotten rid of from the body more quickly. The Cl- becomes HCl.


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## fma08 (Sep 23, 2013)

For those interested (and who have access), there is a review article on Resuscitation Fluids in the New England Journal of Medicine. I haven't looked at it thoroughly yet. Can't seem to find it online for whatever reason. But it is in the Sept. 26th issue. (Vol 369 NO 13).


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## CentralCalEMT (Sep 23, 2013)

In one of the counties I work in, we have LR for volume replacement and that is the primary fluid we use. However, we also have NS in case we need to push medications such as mag sulfate. We also have D5W for our lido drips. However on 99% of patients where you are simply hanging a bag, we use LR. 

In the other county I work in, we use NS for most everything. Thanks to the nationwide shortage of D50, we also carry D10 and give a bolus of that to hypoglycemic patients.


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## NomadicMedic (Sep 23, 2013)

We occasionally restock at a Maryland Hospital and the primary fluid used there is LR. It's easy to grab the wrong bag in a hurry, but there always a flood of emails "make sure you get the correct fluid" when somebody restocks gear with a LR bag instead of Normal Saline.


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## Handsome Robb (Sep 24, 2013)

ResTech said:


> Another common cause of metabolic acidosis is diabetic ketoacidosis(DKA) from hyperglycemia - the primary treatment pre-hospital is a fluid bolus of NSS. So here you can sort of see that NSS does not promote acidosis until given in high volumes such as 2-3 liters and the body is not able to adjust itself to maintain the normal balance which would be the case in severe traumatic injury.



ResTech,I agree that it's a great post. One thing I don't understand though is we've established that NSS in large infusions can promote acidosis. During DKA these patients require massive amounts of fluids so is NSS really the right choice when managing them seeing as the only treatment thats practiced and in my opinion appropriate in the prehospital setting is fluid boluses. Is the limited time we're with these patients enough reason to not consider the potential to worsen the acidosis or is this a situation where we'd be better off with LR?


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