Lactated Ringer

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Lactated Ringers is Superior to
Normal Saline in the Resuscitation of
Uncontrolled Hemorrhagic Shock
S. Rob Todd, MD et al, Journal of TRAUMA Injury,
Infection, and Critical Care, March 2007

• Presented by intern ???

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Introduction

• Treatment of hemorrhage hemostasis volume
  resuscitation
• Normal saline (NS) lactated Ringers solution
  (LR) often used for resuscitation of hemorrhagic
  shock
• Purpose analyze effects of NS and LR on the
  resuscitation of uncontrolled hemorrhagic shock
  in a swine model
• Hypothesis similar effects between NS LR

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Materials and Methods

• Prospective, randomized controlled trial
• N 20 (Yorksire crossbred pigs) underwent
  invasive line placement, midline celiotomy, and
  splenectomy
• Splenectomy prevent variation in amounts of
  sequestered blood
• Grade V liver injury (central hepatic v.) created
  15 min after stabilization
• Resuscitation delayed for 30 minutes to allow
  the animals to reach their nadir blood pressure
• Blindly randomized swine to receive NS or LR
  resuscitation at 165 mL/min to achieve and
  maintain baseline MAP for 90 min postinjury
• Post 2-hour study period blood analysis lactate
  level, ABG, chemistry panel, CBC, PT/PTT,
  fibrinogen, D-dimer

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Results
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NS vs. LR
(p0.02)
(p0.04)
(p0.54)
(p0.34)
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Mean Arterial pressure (MAP)
MAP No significant differences between the
curves (p0.87)
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Lab data
Significant hypernatremia and hypercholremia in
NS group
Persistent hyperchloremia metabolic acidosis in
NS group
Dilutional coagulopathy in NS group
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Discussion

• Plasma chloride concentration was significantly
  greater in the NS group ? persistent acidosis
• Adverse effects of acidosis
• Myocardial contractility (?), peripheral vascular
  resistance(?) , inotropic response to
  catecholamines (?)
• Arrhythmias, platelet dysfunction, and overall
  coagulation cascade dysfunction
• Swafford et al. LR might prolong lactic acid
  load caused by hemorrhage in intoxicated
  individuals
• White et al.
• Lactate metabolized by gluconeogenesis (30) or
  oxidation(70) ? OH- excess ? pH(?)
• Hypothesis increased volume requirement in NS
  group was the result of the significant diuresis

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Discussion

• Dilutional coagulopathy
• Dependent on type and volume of fluid utilized
• In NS animals fibrinogen (?), lower platelet
  count, prolonged PT
• Hypothermia
• Slowing enzymatic reactions of coagulation
  cascade altering platelet function
• Our model prevented by active warming technique
• LR resuscitation serum lactate (?) without an
  associated acidosis

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Summary

• NS resuscitation
• Requires greater volume increased urine output
• Hyperchloremic metabolic acidosis coagulopathy
• LR is superior to NS for the resuscitation of
  uncontrolled hemorrhagic shock in swine

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Thanks for your attention!!!