Written by Aaron Lacy
Spoon Feed
In a secondary analysis of the CLOVERS RCT, patients with sepsis-induced hypotension had improved survival if their first bolus was with lactated ringers (LR) compared to 0.9% normal saline (NS).
LR for sick patients… have you been convinced yet?
Time after time, when the timing and groups in balanced vs. crystalloid studies are scrutinized, balanced fluids come out on top (e.g. sickle cell pain, DKA, children, and more). While the CLOVERS RCT (liberal versus restrictive fluids before vasopressors in sepsis) found no difference in overall mortality between the liberal versus restrictive fluid groups, analysis of patients based on what type of fluids were given didn’t occur.
The authors of this secondary analysis looked at all comers in the CLOVERS RCT, as both the liberal and restrictive groups received at least an initial fluid bolus. Patients with sepsis-induced hypotension who received LR (n=622; 39.8%) had lower death before discharge home by day 90 than those who received NS (n=690; 44.1%) (12.2% vs 15.9%, aHR 0.71; 95%CI 0.51-0.99; p=0.043). Those who received LR also had more hospital-free days at 28 days (16.6 +/- 10.8 vs 15.4 +/- 11.4, adjusted mean difference, 1.6; 95%CI 0.4-2.8; p=0.009).
How will this change my practice?
I have said it before on JournalFeed – first fluids matter when thinking about the LR vs. NS debate. For your ill patient, liters 3, 4, and 5 may not be as relevant as liters 1 and 2. I typically always use LR as a habit now (unless special cases such as TBI). Particularly when placing verbal orders for my sickest patients, I make sure to specifically call for LR, not just a “bolus”, to ensure they are getting the best chance at a good outcome.
Source
Lactated Ringer’s or Normal Saline for Initial Fluid Resuscitation in Sepsis-Induced Hypotension. Crit Care Med. 2025 Feb 19. Doi: 10.1097/CCM.0000000000006601.
