Saline vs. Ringer’s lactate: where is the evidence?
Two very similar* animal studies show that in the setting of acute hemorrhage, less ringer’s lactate than 0,9 % saline is required to achieve a target mean arterial pressure. (1,2)
One human RCT demonstrated that, compared to ringer’s lactate, saline fluid replacement during aortic aneuvrysm repair is associated with larger needs of blood products, but had no effect on intensive care or hospital stay, nor on complications rates. (3) Yet another RCT concludes that in patients undergoing abdominal surgery, both fluids resulted in similar levels of mild coagulopathy and no difference in blood loss. Normal anion gap dilutional/hyperchloremic acidosis** occured only in patients repleted with saline, however. (4)
There is no proven adverse consequences to hyperchloremic acidosis and, as such, current evidence does not permit, in my opinion, to favor any one of the usual resuscitation fluids over the other.
* I seriously wonder if this similarity explains the failure of the later paper’s authors to acknowledge the work of their predecessors.
** To my best knowledge, whether acidosis occurs due to the addition of chloride anions or to the dilution of bicarbonate buffers is far from being established. See Anesthesiology. 87(4):1009-1014 for a lovely discussion of possible mecanisms.
1. Kiraly LN, Differding JA, Enomoto TM, et al. Resuscitation with normal saline (NS) vs. lactated ringers (LR) modulates hypercoagulability and leads to increased blood loss in an uncontrolled hemorrhagic shock swine model. J Trauma. 2006;61(1):57-64
2. Todd SR, Malinoski D, Muller PJ, Schreiber MA. Lactated Ringer’s is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock. J Trauma. 2007;62(3):636-9
3. Waters JH, Gottlieb A, Schoenwald P, Popovich MJ, Sprung J, Nelson DR. Normal saline versus lactated Ringer’s solution for intraoperative fluid management in patients undergoing abdominal aortic aneurysm repair: an outcome study. Anesth Analg. 2001 Oct;93(4):817-22
4. Boldt J, Haisch G, Suttner S, Kumle B, Schellhase F. Are Lactated Ringer’s Solution and Normal Saline Solution
Equal with Regard to Coagulation? Anesth Analg 2002;94:378–84
Dog learns to "pray" for treats
Fecal carriage of MDR Acinetobacter baumanii
Fecal colonization with multiresistant Acinetobacter baumannii was evaluated in 189 consecutive patients in intensive care units (ICUs) during two different 2-month periods (October-November 1993 and May-June 1994). Rectal swabs were obtained weekly from admission to discharge from the ICU. Overall, 77 patients (41%) had multiresistant A. baumannii fecal colonization; colonization was detected in 55 (71%) of the patients within the first week of their ICU stay. Clinical infections due to multiresistant A. baumannii occurred more frequently in patients with fecal colonization than in those without fecal colonization (26% vs. 5%, respectively; P < .001). The reinforcement of isolation measures between study periods reduced both the number of fecal carriers of multiresistant A. baumannii (from 52% to 31%; P < .01) and the number of patients with multiresistant A. baumannii infections (from 17% to 11%; no statistical significance). The digestive tract of ICU patients could be an important epidemiologic reservoir for multiresistant A. baumannii infections in hospital outbreaks. Further prospective studies should be undertaken to define the relative significance of digestive tract colonization compared with other body site colonizations.
Corbella X, et al. Relevance of digestive tract colonization in the epidemiology of nosocomial infections due to multiresistant Acinetobacter baumannii.Clin Infect Dis. 1996;23(2):329-34
RCT shows reduction in mortality and acquisition of resistant bacteria in the ICU
A large RCT convincingly proves that SDD reduces mortality and does not entail the emergence of resistant bacteria.
In the SDD group 69 (15%) patients died in the ICU compared with 107 (23%) in the control group (p=0.002). Hospital mortality was lower in the SDD groups than in the control group (113 [24%] vs 146 [31%], p=0.02). During their stay in intensive care, colonisation with gram-negative bacteria resistant to ceftazidime, ciprofloxacin, imipenem, polymyxin E, or tobramycin occurred in 61 (16%) of 378 SDD patients and in 104 (26%) of 395 patients in the control group (p=0.001). Colonisation with vancomycin-resistant enterococcus occurred in five (1%) SDD patients and in four (1%) controls (p=1.0). No patient in either group was colonised with meticillin-resistant Staphylococcus aureus.
de Jonge et al. Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial. The Lancet 2003; 362:1011-1016
