Comparisons of normal saline and lactated Ringer's resuscitation on hemodynamics, metabolic responses, and coagulation in pigs after severe hemorrhagic shock

Wenjun Z Martini, Douglas S Cortez, Michael A Dubick, Wenjun Z Martini, Douglas S Cortez, Michael A Dubick

Abstract

Background: Ongoing improvements in trauma care now recommend earlier use of blood products as part of damage control resuscitation, but generally these products are not available at far forward battlefield locations. For the military, questions continue to arise regarding efficacy of normal saline (NS) vs. lactated Ringer's (LR). Thus, this study compared the effects of LR and NS after severe hemorrhage in pigs.

Methods: 20 anesthetized pigs were randomized into control (n = 6), LR (n = 7), and NS (n = 7) groups. Hemorrhage of 60% estimated total blood volume was induced in LR and NS groups by removing blood from the left femoral artery using a computer-controlled pump. Afterwards, the pigs were resuscitated with either LR at 3 times the bled volume or the volume of NS to reach the same mean arterial pressure (MAP) as in LR group. Hemodynamics were measured hourly and blood samples were taken at baseline (BL), 15 min, 3 h and 6 h after resuscitation to measure changes in coagulation using thrombelastograph®.

Results: MAP was decreased by hemorrhage but returned to BL within 1 h after resuscitation with LR (119 ± 7 ml/kg) or NS (183 ± 9 ml/kg, p < 0.05). Base excess (BE) was decreased by hemorrhage; resuscitation with LR recovered BE but not with NS. Total peripheral resistance was decreased with NS and LR, with a larger drop shown in NS. Serum potassium was increased with NS, but not affected with LR. Coagulation changes were similar between LR and NS.

Conclusions: NS may be inferior to LR in resuscitation due to its vasodilator effects and the risks of metabolic acidosis and hyperkalemia.

Figures

Figure 1
Figure 1
Experimental protocol.
Figure 2
Figure 2
Changes in mean arterial pressure (MAP), heart rate (HR), and urine output after hemorrhage and resuscitation with lactated Ringer’s solution (LR, 119 ± 7 ml/kg) or normal saline (NS, 183 ± 9 ml/kg) in pigs. *p < 0.05 compared to the corresponding baseline values. ♣p < 0.05 compared to corresponding control values.
Figure 3
Figure 3
Changes in oxygen delivery (A), oxygen consumption (B), oxygen demand (C), and oxygen delivery/oxygen demand (D) after hemorrhage and resuscitation with lactated Ringer’s solution (LR, 119 ± 7 ml/kg) or normal saline (NS, 183 ± 9 ml/kg) in pigs. *p < 0.05 compared to the corresponding baseline values. §p < 0.05 LR group compared to NS group. ♣p < 0.05 compared to corresponding control values.
Figure 4
Figure 4
Changes in acid-base status after hemorrhage and resuscitation with lactated Ringer’s solution (LR, 119 ± 7 ml/kg) or normal saline (NS, 183 ± 9 ml/kg) in pigs. *p < 0.05 compared to the corresponding baseline values. §p < 0.05 LR group compared to NS group. ♣p < 0.05 compared to corresponding control values.
Figure 5
Figure 5
Changes in Thrombelastograph® (TEG) measurements after hemorrhage and resuscitation with lactated Ringer’s solution (LR, 119 ± 7 ml/kg) or normal saline (NS, 183 ± 9 ml/kg) in pigs. R time: latency time for initial fibrin formation. K time: a measure of speed to reach a certain level of clot strength. Angle a: the rapidity of fibrin build up and cross-linking. MA: maximum strength of the developed clot. *p < 0.05 compared to the corresponding baseline values.

References

    1. Mullins RJ. Management of Shock. Philadelphia, Stamford, CT: Appleton & Lange; 1996.
    1. Maier RV. In: Surgery:Scientific Principles and Practice. 2. Greenfield LJ, Mulholland MW, Oldham KT, Zelenock GB, Lillemoe KD, editor. Philadelphia, PA: Lippincott-Raven; 1997. Shock; pp. 182–215.
    1. Tapia NM, Suliburk J, Mattox KL. The initial trauma center fluid management of penetrating injury: a systematic review. Clin Orthop Relat Res. 2013;21(12):3961–3973. doi: 10.1007/s11999-013-3122-4.
    1. Duchesne JC, Heaney J, Guidry C, McSwain N Jr, Meade P, Cohen M, Schreiber M, Inaba K, Skiada D, Demetriades D. et al.Diluting the benefits of hemostatic resuscitation: a multi-institutional analysis. J Trauma Acute Care Surg. 2013;21(1):76–82. doi: 10.1097/TA.0b013e3182987df3.
    1. Carlino W. Damage control resuscitation from major haemorrhage in polytrauma. Eur J Orthop Surg Traumatol. 2013. [Epub ahead of print]
    1. Dutton RP. Haemostatic resuscitation. Br J Anaesth. 2012;21(Suppl 1):i39–i46. doi: 10.1093/bja/aes389.
    1. Spoerke N, Michalek J, Schreiber M, Brasel KJ, Vercruysse G, MacLeod J, Dutton RP, Duchesne JC, McSwain NE, Muskat P. et al.Crystalloid resuscitation improves survival in trauma patients receiving low ratios of fresh frozen plasma to packed red blood cells. J Trauma. 2011;21(2 Suppl 3):S380–S383.
    1. Foex BA. How the cholera epidemic of 1831 resulted in a new technique for fluid resuscitation. Emerg Med J. 2003;21(4):316–318. doi: 10.1136/emj.20.4.316.
    1. Awad S, Allison SP, Lobo DN. The history of 0.9% saline. Clin Nutr. 2008;21(2):179–188. doi: 10.1016/j.clnu.2008.01.008.
    1. Belani KG, Palahniuk RJ. Kidney transplantation. Int Anesthesiol Clin. 1991;21(3):17–39. doi: 10.1097/00004311-199122000-00003.
    1. Banks AAoB. Accreditation Requirements Manual. 5. Arlington: American Association of Blood Banks; 1994.
    1. Wilkes NJ, Woolf R, Mutch M, Mallett SV, Peachey T, Stephens R, Mythen MG. The effects of balanced versus saline-based hetastarch and crystalloid solutions on acid-base and electrolyte status and gastric mucosal perfusion in elderly surgical patients. Anesth Analg. 2001;21(4):811–816. doi: 10.1097/00000539-200110000-00003.
    1. Williams EL, Hildebrand KL, McCormick SA, Bedel MJ. The effect of intravenous lactated Ringer’s solution versus 0.9% sodium chloride solution on serum osmolality in human volunteers. Anesth Analg. 1999;21(5):999–1003.
    1. Scheingraber S, Rehm M, Sehmisch C, Finsterer U. Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery. Anesthesiology. 1999;21(5):1265–1270. doi: 10.1097/00000542-199905000-00007.
    1. 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;21(4):817–822. doi: 10.1097/00000539-200110000-00004.
    1. O’Malley CM, Frumento RJ, Hardy MA, Benvenisty AI, Brentjens TE, Mercer JS, Bennett-Guerrero E. A randomized, double-blind comparison of lactated Ringer’s solution and 0.9% NaCl during renal transplantation. Anesth Analg. 2005;21(5):1518–1524. doi: 10.1213/01.ANE.0000150939.28904.81. table of contents.
    1. Healey MA, Davis RE, Liu FC, Loomis WH, Hoyt DB. Lactated ringer’s is superior to normal saline in a model of massive hemorrhage and resuscitation. J Trauma. 1998;21(5):894–899. doi: 10.1097/00005373-199811000-00010.
    1. Traverso LW, Hollenbach SJ, Bolin RB, Langford MJ, DeGuzman LR. Fluid resuscitation after an otherwise fatal hemorrhage: II. Colloid solutions. J Trauma. 1986;21(2):176–182. doi: 10.1097/00005373-198602000-00015.
    1. Kiraly LN, Differding JA, Enomoto TM, Sawai RS, Muller PJ, Diggs B, Tieu BH, Englehart MS, Underwood S, Wiesberg TT. 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;21(1):57–64. doi: 10.1097/01.ta.0000220373.29743.69.
    1. Lairet JR, Bebarta VS, Burns CJ, Lairet KF, Rasmussen TE, Renz EM, King BT, Fernandez W, Gerhardt R, Butler F. et al.Prehospital interventions performed in a combat zone: a prospective multicenter study of 1,003 combat wounded. J Trauma Acute Care Surg. 2012;21(2 Suppl 1):S38–S42.
    1. Butler FK. Tactical combat casualty care: update 2009. J Trauma. 2010;21(Suppl 1):S10–S13.
    1. Lipsky AM, Ganor O, Abramovich A, Katzenell U, Glassberg E. Walking between the drops: Israeli defense forces’ fluid resuscitation protocol. J Emerg Med. 2013;21(4):790–795. doi: 10.1016/j.jemermed.2012.08.029.
    1. Holcomb JBSP. Optimal use of blood in trauma patients. Biologicals. 2010;21(1):6.
    1. Burns JW, Baer LA, Darlington DN, Dubick MA, Wade CE. Screening of potential small volume resuscitation products using a severe hemorrhage sedated swine model. Int J Burns Trauma. 2012;21(1):59–67.
    1. Salomone JP PP. Prehospital Trauma Life Support: Military Version. 6. St. Louis, Missouri: MOSBY Elsevier; 2007.
    1. Sondeen JL, Prince MD, Kheirabadi BS, Wade CE, Polykratis IA, de Guzman R, Dubick MA. Initial resuscitation with plasma and other blood components reduced bleeding compared to hetastarch in anesthetized swine with uncontrolled splenic hemorrhage. Transfusion. 2011;21(4):779–792. doi: 10.1111/j.1537-2995.2010.02928.x.
    1. Hannon JP, Wade CE, Bossone CA, Hunt MM, Loveday JA. Oxygen delivery and demand in conscious pigs subjected to fixed-volume hemorrhage and resuscitated with 7.5% NaCl in 6% Dextran. Circ Shock. 1989;21(3):205–217.
    1. 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;21(5):535–539. doi: 10.1080/08860220802064770.
    1. Martini WZ, Pusateri AE, Uscilowicz JM, Delgado AV, Holcomb JB. Independent contributions of hypothermia and acidosis to coagulopathy in swine. J Trauma. 2005;21(5):1002–1009. doi: 10.1097/01.TA.0000156246.53383.9F. discussion 1009–1010.
    1. Martini WZ, Dubick MA, Pusateri AE, Park MS, Ryan KL, Holcomb JB. Does bicarbonate correct coagulation function impaired by acidosis in swine? J Trauma. 2006;21(1):99–106. doi: 10.1097/01.ta.0000215574.99093.22.
    1. Hartmann AF, Senn MJ. Studies in the metabolism of sodium r-lactate. III. Resuponse of human subjects with liver damage, disturbed warter and mineral balance, and renal insufficiency to the intravenous injection of sodium r-lactate. J Clin Invest. 1932;21(2):345–355. doi: 10.1172/JCI100416.
    1. Park MS, Martini WZ, Dubick MA, Salinas J, Butenas S, Kheirabadi BS, Pusateri AE, Vos JA, Guymon CH, Wolf SE. et al.Thromboelastography as a better indicator of hypercoagulable state after injury than prothrombin time or activated partial thromboplastin time. J Trauma. 2009;21(2):266–275. doi: 10.1097/TA.0b013e3181ae6f1c. discussion 275–266.
    1. Martini WZ, Cortez DS, Dubick MA, Park MS, Holcomb JB. Thrombelastography is better than PT, aPTT, and activated clotting time in detecting clinically relevant clotting abnormalities after hypothermia, hemorrhagic shock and resuscitation in pigs. J Trauma. 2008;21(3):535–543. doi: 10.1097/TA.0b013e31818379a6.
    1. Bellamy RF, Maningas PA, Wenger BA. Current shock models and clinical correlations. Ann Emerg Med. 1986;21(12):1392–1395. doi: 10.1016/S0196-0644(86)80922-2.
    1. Bickell WH, Wall MJ Jr, Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994;21(17):1105–1109. doi: 10.1056/NEJM199410273311701.
    1. Hahn RG. Fluid therapy in uncontrolled hemorrhage–what experimental models have taught us. Acta Anaesthesiol Scand. 2013;21(1):16–28. doi: 10.1111/j.1399-6576.2012.02763.x.
    1. Halperin ML, Kamel KS. Potassium. Lancet. 1998;21(9122):135–140. doi: 10.1016/S0140-6736(98)85044-7.
    1. Martini WZ, Dubick MA, Blackbourne LH. Comparisons of lactated Ringer’s and Hextend resuscitation on hemodynamics and coagulation following femur injury and severe hemorrhage in pigs. J Trauma Acute Care Surg. 2013;21(3):732–740. doi: 10.1097/TA.0b013e31827f156d.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera