saline vs hartmann's solution (audit)
TRANSCRIPT
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Saline vs Hartmann’s SolutionThe debate
Dr J Groves
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Q. What is this?
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A. vibrieo cholerae
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Thomas Latta & William O’Shaughnessy
• William O’Shaughnessy noted blood from cholera victims had lost ‘a large proportion of its water’. He suggested replacing it with its ‘deficient saline’.
• Thomas Latta used saline in 1832 in cholera victims with ‘dramatic effects’
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Sydney Ringer FRS
• Physiologist at UCL & GOS
• Developed his solution while studying the frog heart 1882-1885.
• Ran out of distilled water for experiments and used tap water. This increased contractility and he deduced it was the disolved calcium.
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Sir Leonard Rogers FRS
Successfully used saline in the treatment of disease while in India as a military surgeon.
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Alexis Hartmann
American pediatrician.
Modified Ringer’s solution by adding lactate in the 1930’s. This provided an intravenous fluid that led to less fluid induced acidosis.
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Solution’s Compared
Hartmann’s • Na 131• K 5• Ca 2• Cl 111• Lactate 29
Osmolality 278
0.9% Saline
Na 151
Cl 151
Osmolality 302
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Does the nature of the fluid matter?
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Audit Results from 2005ishWhat fluid we thought we used
Primary Fluid Used Minor Major Diabetic Emergency
Saline 6 2 15 4Hartmann's 8 21 7 15What ever 9 0 0 4
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Audit ResultsWhat we probably used
Fluid Consultant Trainee Em Lap
Saline 11 9 11Hartmann's 2 4 2What ever 0 0 0
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I like…..hate
I like saline because..• You can give it to
anyone• Its good in diabetics• I’ve always used it• My great great
grandfather used it
I hate saline because..• It’s got too much
sodium in it• It’s got too much
chloride in it• My great great great
grandfather used it
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I like…..hate
I like Hartmann’s because
• Its got lactate in it• It doesn’t produce an
acidosis on infusion• It was invented
originally by a Brit
I hate Hartmann’s because
• Its got lactate in it• You can’t use it in
diabetics• It was invented by an
American
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Most Popular Fluid?
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Fluid usage in theatres
02000400060008000
10000120001400016000
2004-2005
2005-2006
2006-2007
Lit
res
Saline l
saline .5l
Hartmans l
Hartmans 0.5l
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Disadvantages of Hartmann’s
• Neonates
• Neurosurgery– Hartmann’s mildly decreases serum osmolality– Decreases serum sodium
• Lactate
• Marginally more expensive (6p/litre)
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Disadvantages of Saline
• Contains lots of chloride
• In healthy volunteers (50ml/kg over an hour) it:– Leads to a metabolic acidosis– Reduces urine output (time to first micturition)– Leads to abdominal discomfort– Produces subjective mental changes
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Disadvantages of Saline
• Worse outcome after saline resuscitation than Hartmann’s in model of massive haemorrhage.
• Impairs gastro-pyloric motility in pigs, suggesting a role in post op gastroparesis & vomiting
• Reduces gastric mucosal perfusion in elderly surgical patients
• Patients undergoing aneurysm repair need more blood products if saline is used than if Hartmann’s is used.
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Does the chloride in saline concern you?
0
5
10
15
20
25
Yes No Yes No
Minor Minor Major Major
Chloride
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What about smaller volumes?
• Volunteers given 2 litres of saline vs Hartmann’s. – 56% saline vs 30% Hartmann’s retained at 6 hours.
– Faster time to first uriniation in Hartmann’s group (70 vs 185 mins). (effect of saline on ADH)
– Higher urinary sodium in the Hartmann’s group! (effect of hyperchloraemia on glomeruli and renal blood flow)
– Bulk of the saline remained in the interstitial space. (Concern about oedema from repeat infusions)
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You Haven’t mentioned the Lactate or Potassium
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Do the lactate or potassium in Hartmann's concern you?
0
24
68
1012
1416
18
No Yes
Lactate
Potassium
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Lactate
• Turn over 1300mmol/24hrs (as high as glucose).
• All tissues release it (save islet cells)• Serum level 1mmol/litre• Essential for red cell metabolism and the
heart liver and kidneys utilise it as an energy source
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Cori Cycle
(Diagram from Leeds dental school)
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Lactate
• Lactate is an important intermediary metabolite for numerous metabolic process and is a central player in regional and whole body metabolism.
• Improves cardiac function when infused in models of haemorrhagic shock
• Neuroprotective
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Lactate
• Doesn’t cause acidosis as, under normal conditions, it can’t release a proton.
• Under high metabolic states H+ production from the hydrolysis of ATP exceeds buffering capacity
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What about Potassium?
• Serum potassium is ~ 4mmol/litre
• Predominantly intracellular (98%). There are about 80mmol K+ in extracellular fluid
• Giving a litre of Hartmann’s will only raise the serum potassium by 1/21 (0.05)mmol.
• If the K+ is over 5mmol/litre giving Hartmann’s will lower it
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What about Potassium?
• If you become acidotic as a consequence of an organic acid ( lactic acid) the organic ion moves into the cell with H+
• If you become acidotic as a consequence of an inorganic acid (HCL) the H+ moves into the cells but the CL- stays extra-cellular and K+ moves out of the cell raising serum potassium.
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What about diabetics?
• 30 mmol lactate will be metabolised to form 15mmol glucose consuming 30 mmol of H+ ions. This in resting conditions will be stored as glycogen
• 5% Glucose contains 50mmol of glucose/litre
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Primary fluid used
0
5
10
15
20
25
Minor Major Diabetic Emergency
Saline
Hartmann's
What ever
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Should we do anything?
• There are no outcome studies saying one fluid is better than another.
• The evidence is highly suggestive that if we wish to maintain physiological normality we should use a balanced salt solution.
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Proposal
• We instruct the ODP’s to always run through Hartmann’s Solution unless there is a specific request to the conrary
• We have bigger Hartmann’s stores and smaller saline stores in the anaesthetic rooms
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What about the cost
All Hartmann’s
£13,791
All Saline
£12,127
£1664 Less
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Does audit influence practice?
Hartmans
500
600
700
800
900
1000
1100
July August September October
Hartmans
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And Finally…
“Saline induced acidosis has a side effect profile similar to that of ammonium
chloride”
K Gunnerson
Why not repeat this hospital wide?