Written by Clay Smith.
Take a Balanced Approach
With all the talk of using balanced, lower chloride solutions for volume in the ED and ICU, we thought it might be a good idea to discuss the potential downsides of LR.
What’s in There?
Adapted from http://sites.utexas.edu/pharmacotherapy-rounds/files/2015/09/hernandez05-05-2013.pdf
When to Avoid LR
1. Avoid LR with PRBC Transfusions
Since LR contains calcium, it should not be run with PRBC transfusions, because it could make the blood clot. That’s a problem. However, it may be given simultaneously if through a separate IV at another site. There is some evidence that if the transfusion is given rapidly with LR added, it doesn’t matter. Generally, it is not a good practice to run LR with PRBCs. In fact, just avoid this. Plus, this will be on your boards. Hint – the right answer is NS. Plasma-Lyte is fine to give with PRBCs.
2. Be Wary of Hyponatremia
Since LR has only 131 mEq/L Na, it may contribute to hyponatremia with large volume infusions. However, in this study, postoperative hyponatremia may have more to do with overly aggressive fluid resuscitation than with LR itself. Over-expansion of extracellular fluid is postulated to lead to excess ADH release and subsequent hypertonic urine.
3. What about LR with Severe Hyperkalemia?
There is much debate about this. LR has potassium in it, but studies in humans suggest that giving NS with the ensuing hyperchloremic metabolic acidosis is more detrimental to potassium levels than LR because the acidosis reduces intracellular shift of potassium. If a patient already has severe hyperkalemia, the best initial fluid bolus may be isotonic sodium bicarbonate–although this is admittedly an evidence-free zone.
4. Avoid LR with Certain Medications
LR has not been studied as a diluent to most medications, so you may get warning pop-ups on your computer when you are giving LR and adding a medication. For example, because of the calcium in LR, it could cause precipitants if given with cetriaxone. While ceftriaxone could still be given to adult patients using LR as the diluent, there is a strong contraindication to co-administering any calcium containing fluids with ceftriaxone in young children due to case reports of neonatal deaths.
5. What about LR in Traumatic Brain Injury?
We don’t know. It may worsen outcome in patients with TBI compared to NS, but we don’t yet have high quality evidence.
Peer reviewed by Thomas Davis.
I would add a sixth category or an add-on to #1 — avoid using LR fluid resuscitation of patients with hypercalemia because LR contains calcium.
Matt Felbinger’s addition is theoretically correct. However, I had a patient once who presented with severe hypercalcemia and although I ordered 0.9% NaCl, the nurse accidentally used LRS. This was noticed four hours later when recheck electrolytes were ordered. Low and behold, the calcium had dropped significantly.
Probably the most important thing is renal blood flow with subsequent diuresis. Thanks for the feedback.
Lo and behold 🙂