lactated ringers and lactate clearance

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
VentdependenT

VentdependenT

You didnt build thaT
Moderator Emeritus
Verified Member
Physician
15+ Year Member
Joined
Oct 3, 2003
Messages
4,007
Reaction score
27
I often get asked if lactated ringers worsens lactic acidosis...
I've been told that lactated ringers will worsen lactic acidosis in liver failure...
I've been asked if the lactate in lactated ringers will "falsely" elevate lab values.

Personally, this is my go to crystalloid. Plasmalyte would be my only choice if it didnt cost 2-3x as much as LR.

I know the answers to the above but would like to hear your thoughts. Now with lactate being the new marker for adequate resuscitation in sepsis I think its a good topic.
Members don't see this ad.
 
VentdependenT said:
I often get asked if lactated ringers worsens lactic acidosis...
I've been told that lactated ringers will worsen lactic acidosis in liver failure...
I've been asked if the lactate in lactated ringers will "falsely" elevate lab values.

Personally, this is my go to crystalloid. Plasmalyte would be my only choice if it didnt cost 2-3x as much as LR.

I know the answers to the above but would like to hear your thoughts. Now with lactate being the new marker for adequate resuscitation in sepsis I think its a good topic.
Click to expand...

Yes, it can falsely elevate serum lactate numbers and it it definitely more pronounced in bad livers.

And I don't know why you'd use LR or Plasmalyte instead of NS for just about anything (unless of course you have stock in Baxter)
 
Members don't see this ad :)
I look @ the base labs, if they aren't already hyperchloremic ill start with NS, which I use for the 20mL/kg bolus, I tend to use LR for the second set of bolus, which comes after when I draw the lactic. I don't tend to redrawn lactic ~6 hour mark. Anecdotally it's I've not had many lactic acids bump but I know the LR can confound the data but is like to think I'm not givin much LR and waiting long enough to clear what little I give.
 
0.9 is so non-physiologic its ridiculous. After 3L of this garbage lytes get wacked, so i almost always switch to LR at that point anyways. The Ph is 5.0. LR ph is 6.5. Plasmalyte 7.4. The .9's slightly elevated osms aint worth it.

Now with sepsis guidelines stating that albumin should be considered after "considerable amounts of crystalloid have been given" I can basically ditch 0.9 in all non-hyperkalemics if plasma osmols become an issue....mainly academic.
 
Hernandez said:
http://pulmccm.org/2012/randomized-...oride-solutions-may-cause-renal-failure-jama/

Chloride isn't benign. I'm not entirely sure what to do with this info but I've stopped using solely NS since this paper came out and have used more LR since then.
Click to expand...

It also doesn't really seem to matter when the rubber meets the road - no difference in mortality, hospital length of stay, and . . . drum roll . . . need for dialysis after d/c

I'll wait for the randomized trial. I've been burned one too many times by sexy observational data.

If I don't have a reason not to use NS, I'm using it.
 
jdh71 said:
It also doesn't really seem to matter when the rubber meets the road - no difference in mortality, hospital length of stay, and . . . drum roll . . . need for dialysis after d/c

I'll wait for the randomized trial. I've been burned one too many times by sexy observational data.

If I don't have a reason not to use NS, I'm using it.
Click to expand...

I agree, but it's a thought provoking study to me, especially since LR is cheap, and doesn't have many potential downsides in this particular pt population, I've not become a surgeon who uses nothing but LR, but I'm not finding myself giving the same levels of NS these days.
 
Hernandez said:
I agree, but it's a thought provoking study to me, especially since LR is cheap, and doesn't have many potential downsides in this particular pt population, I've not become a surgeon who uses nothing but LR, but I'm not finding myself giving the same levels of NS these days.
Click to expand...

I can't get the editorial to open through the U - ugh. Don't know if it's the JAMA site or the U library.

Hmm. I may reconsider bring in more LR.
 
VentdependenT said:
I often get asked if lactated ringers worsens lactic acidosis...
I've been told that lactated ringers will worsen lactic acidosis in liver failure...
I've been asked if the lactate in lactated ringers will "falsely" elevate lab values.
.
Click to expand...


Lacate is the buffer in the solution and has the same negative BE as all other crystalloid if the liver can not convert the lactate to bicarb. So I believe the answers to your questions are as follows.
1) No
2) No
3) Sure, if you use a ton of LR especially in a patient with liver failure your pt will have elevated lactate levels which may be misinterpreted as lactic acidosis, always need to look at all the labs.

Large number of things can cause elevated lactate levels but have nothing to do with tissue hypo perfusion
 
I have written for a change to LR after the first 20-30ml/kg of NS. Most of my unit pts are not cirrhotics, and those that are are usually anasarcic and Have massive respiration restrictive ascites +/- pulmonary edema so they get no fluid. For the septics I have had several attendings change my orders with the "they're sick they can't convert lactate to bicarbonate" reasoning. I do not think they are correct but I know when to and when to not argue. I'm on nights now so I'm gonna keep writing for it and see if my day team starts catching on. The chief is on days this month and maybe he can reason with the current not-so-up-to-date-on-current ebm attending that's on.
 
Members don't see this ad :)
Bostonredsox said:
not-so-up-to-date-on-current ebm attending that's on.
Click to expand...

You need to be careful with this thought process. EBM medicine isn't evidence based. And older docs have seen enough fades and swings in what is and isn't in vogue to not adjust their practice without damn good reason.
 
VentdependenT said:
I often get asked if lactated ringers worsens lactic acidosis...
I've been told that lactated ringers will worsen lactic acidosis in liver failure...
I've been asked if the lactate in lactated ringers will "falsely" elevate lab values.

Personally, this is my go to crystalloid. Plasmalyte would be my only choice if it didnt cost 2-3x as much as LR.

I know the answers to the above but would like to hear your thoughts. Now with lactate being the new marker for adequate resuscitation in sepsis I think its a good topic.
Click to expand...

1) No. LR will not worsen lactic acidosis. LR will also not worsen hyperkalemia appreciably.
2) No. It will, however, potentially result in increased laboratory values of lactate... because the lab doesn't measure biologically active lactate - it measures one of the breakdown products.... which is in turn broken down by the liver. Liver failure = increased breakdown product that is benign but picked up by the lab test. The way you can tell is that the patient's lactate will be stubbornly high but the pH is much better than you would otherwise expect. Happens in shock liver all the time.
3) I keep it simple: Sodium under 140, I give NS. Sodium over 140, I give LR. If sodium under 140 and chloride high, I will often still go with LR anyway.

By the way, for more reading on the evil of chloride, see Stewart and the strong-ion difference...
 
I love talking about fluids (that sounded dirtier than I thought).

However, even now I am constantly confused by fluid choices. On the wards I have never seen people use LR only NS. In ICU or OR I have only seen people use LR.

Are there general indications for when you would use what? This is coming from a medical student. Also, since someone mentioned, what are people's views on Stewart? Evil? Awesome? Stew-who? I know some consultants who probably have wet dreams about Stewart Acid-Base while others have nightmares.
 
KLPM said:
I love talking about fluids (that sounded dirtier than I thought).

However, even now I am constantly confused by fluid choices. On the wards I have never seen people use LR only NS. In ICU or OR I have only seen people use LR.

Are there general indications for when you would use what? This is coming from a medical student. Also, since someone mentioned, what are people's views on Stewart? Evil? Awesome? Stew-who? I know some consultants who probably have wet dreams about Stewart Acid-Base while others have nightmares.
Click to expand...

Stewart is conceptually really cool - explains everything we see in acid base in a way that so much easier to deal with than classical understanding.

With that said, it's not like knowing this effectively changes much of anything, nor does it change or really direct management. Though the Australian paper referenced earlier, might be some of the first stuff showing in a practical way how it all can make a difference. It's also got my investigative juices flowing a bit . . .
 
I will basically use a bastardized version of Stewart's when interpreting complex met/resp acid/base disorders. But really it's probably overkill for most issues.

I'm a huge fan of Lawrence Martin's book http://www.lakesidepress.com/pulmonary/index-phys.html. And he even has several chapters online for free. Unlike 99.99% of ABG books he actually goes through the 2nd and 3rd order acid base issues. He even gives a nice over view of base deficit and its use.
 
1. LR does not "increase" serum lactate, and even if it did, it is not the high lactate in and of itself that is at the root of the badness, it is the tissue hypoperfusion, for which lactate is a marker.
2. NS causes a hyperchloremic acidosis, as in the articles above. Mix and match actually is not a bad idea. I nnever use Plasmalyte. Any data or articles on it?
 
sluggs said:
1. LR does not "increase" serum lactate, and even if it did, it is not the high lactate in and of itself that is at the root of the badness, it is the tissue hypoperfusion, for which lactate is a marker.
2. NS causes a hyperchloremic acidosis, as in the articles above. Mix and match actually is not a bad idea. I nnever use Plasmalyte. Any data or articles on it?
Click to expand...

1) it has been shown to increase serum lactate levels which we look at when we send the lab....., at less when compared to NS in the PTs studied, but it's doesn't cause the acidemia. But it typically takes way more than 1-2 liters....in healthy adults. If I remember I believe the way Marino words it in the ICU book is 1L over 1 hour of LR in a healthy adult does not increase the lactate level....hens the last time you had a healthy adult in the Icu You have LR to for ****s and giggles. So yes it can skew the lab work even of the end result isn't a change in the clinical picture Here's one quick reference to show it can.

http://www.ncbi.nlm.nih.gov/m/pubmed/18635497/
 
Hernandez said:
1) it has been shown to increase serum lactate levels which we look at when we send the lab....., at less when compared to NS in the PTs studied, but it's doesn't cause the acidemia. But it typically takes way more than 1-2 liters....in healthy adults. If I remember I believe the way Marino words it in the ICU book is 1L over 1 hour of LR in a healthy adult does not increase the lactate level....hens the last time you had a healthy adult in the Icu You have LR to for ****s and giggles. So yes it can skew the lab work even of the end result isn't a change in the clinical picture Here's one quick reference to show it can.

http://www.ncbi.nlm.nih.gov/m/pubmed/18635497/
Click to expand...

It's not just that it can skew the lab work but doesn't "change the clinical picture".

It is that it can skew the lab work and is not at all REFLECTIVE of the clinical picture.

The lactate in LR infusion is a biologically inactive form, a buffer. The lactate that your body generates in response to anaerobic activity (i.e. reflective of malperfusion as noted by an above poster) is indicative of the clinical picture.

Trouble is, your lab test can't tell the difference.

Bottom line: Those who demonize LR for the "lactate" that is in it, don't fully appreciate the chemistry involved, the limitations of the lab tests.
 
emergiQ said:
It's not just that it can skew the lab work but doesn't "change the clinical picture".

It is that it can skew the lab work and is not at all REFLECTIVE of the clinical picture.

The lactate in LR infusion is a biologically inactive form, a buffer. The lactate that your body generates in response to anaerobic activity (i.e. reflective of malperfusion as noted by an above poster) is indicative of the clinical picture.

Trouble is, your lab test can't tell the difference.

Bottom line: Those who demonize LR for the "lactate" that is in it, don't fully appreciate the chemistry involved, the limitations of the lab tests.
Click to expand...

Gotta be honest, I'm just not sure who you're arguing with in here, because I don't think anyone suggested that the lactate in the LR made patients worse.
 
jdh71 said:
Gotta be honest, I'm just not sure who you're arguing with in here, because I don't think anyone suggested that the lactate in the LR made patients worse.
Click to expand...

Yeah, I think I misread Hernandez' post. Sorry, H. I believe I just dumbly parroted the point you were trying to make!
 
You must log in or register to reply here.
Next unread thread
Top