People worry about the potassium levels in Lactated Ringer’s (Ringers Lactate), but what if I told you there’s more hyperkalemia with saline? 0.9% saline is 154mmol/L of sodium and 154mmol/L of chloride. That’s it. There’s no potassium, calcium, magnesium, or buffering agent. Ringer’s lactate, however, has 130mmol/L of sodium, 109mmol/L of chloride, 4mmol/L of potassium, 28mmol/L of lactate, and 3mmol/L of calcium. One would expect that the solution containing potassium would cause a greater increase in potassium than the one without potassium, right? Well, not so fast. Large volumes of sodium chloride produce hyperchloremic metabolic acidosis. What happens during acidosis? There’s a potassium shift from the intracellular space to the extracellular space. Much of this concerns the strong ion difference, which I will explain shortly.
Study #1 Looking at Potassium Increase in Saline vs. Ringers Lactate
In this study, 52 patients patients received either LR or NS during their renal transplants. Here are the findings: This has been copied and pasted from the article. Please download it and read it for yourself.
“Patients in the NS group had a lower mean PH level during the transplantation compared with those who received LR (p < 0. 001).
Mean serum potassium levels in the NS and LR groups were 4.88 ± 0.7 and 4.03 ± 0.8 meq/L, respectively (p < 0.001).
Mean changes of the serum potassium were +0.5 ± 0.6 meq/L in the NS group and –0.5 ± 0.9 meq/L in the LR group (p < 0.001).
Mean changes of PH were −0.06 ± 0.05 in the NS group and –0.005 ± 0.07 in the LR group (p < 0.001)”
If next time someone tells you that LR causes hyperkalemia, you can be armed with data. I have other articles with similar results that I plan on sharing in the upcoming days.
I don’t know what to make of that thrombosis phenomenon they found. Must keep an eye out for more data regarding that.
Check out my whole IV fluid guide here: http://eddyjoemd.com/ivf-guide/
Study #2 Looking at Potassium Increase in Saline vs. Ringers Lactate
Yet another article discusses Ringer’s Lactate versus 0.9% saline solution in renal transplant patients. They also acknowledged the consensus to provide NS rather than LR to avoid hyperkalemia. Still, they weren’t happy with that, especially understanding and running into the data suggesting that NS creates the non-anion gap metabolic acidosis from hyperchloremia, which can result in hyperkalemia due to the extra-cellular shift of potassium. That’s why they decided to proceed with a prospective, double-blind clinical trial on patients undergoing kidney transplants.
They had 37 patients in each group. Each group of patients, the LR and the NS groups, received a little more than 5L each. Patients who received NS had a pH drop from 7.43 to 7.33. The LR group had no change in pH. The table in the article breaks down the serum electrolytes during the study, as they were checked four times throughout the surgery. The authors concluded that RL may be safe and superior to NS in these patients. The article cites another study where that team had to treat more patients for hyperkalemia in the NS arm than in the LR arm. Cool stuff, right? A 🎩 tip to the authors!
-EJ
Citations
Khajavi MR, Etezadi F, Moharari RS, Imani F, Meysamie AP, Khashayar P, Najafi A. Effects of normal saline vs. lactated ringer’s during renal transplantation. Ren Fail. 2008;30(5):535-9. doi: 10.1080/08860220802064770. PMID: 18569935.
Link to Article
Link to FULL FREE PDF
Modi MP, Vora KS, Parikh GP, Shah VR. A comparative study of impact of infusion of Ringer’s Lactate solution versus normal saline on acid-base balance and serum electrolytes during live related renal transplantation. Saudi J Kidney Dis Transpl. 2012 Jan;23(1):135-7. PMID: 22237237.
Link to Abstract
Link to FULL FREE PDF
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