Normal Saline Vs Lactated Ringers in Hemorrhagic Shock

Choice of crystalloid as a resuscitation fluid in the face of known hemorrhagic shock remains one of the most highly debated topics in the trauma literature at this time. While many clinicians consider lactated Ringer’s and normal saline interchangeable, they are not.

Multiple studies in the swine model compare the use of various crystalloid solutions, focusing on lactated Ringer’s solution and normal saline. The swine model demonstrates that if shock is induced and maintained for 30 min, followed by resuscitation with either normal saline or lactated Ringer’s solution, the animals resuscitated with Ringer’s lactate have better improvement in markers of shock, pH, and extracellular lung water. In this study neutrophil activation contributes to cellular damage. Other studies support the neutrophil activation phenomenon; dextran is the biggest activator, followed by normal saline and then lactated Ringer’s

·         Phillips CR, Vinecore K, Hagg DS, Sawai RS, Differding JA, Watters JM, Schreiber MA. Resuscitation of haemorrhagic shock with normal saline vs. lactated Ringer’s: effects on oxygenation, extravascular lung water and haemodynamics. Crit Care. 2009;13(2):R30. Epub 2009 Mar 4.

·          Scultetus A, Alam HB, Stanton K, et al. Dextran and Hespan resuscitation causes neutrophil activation in swine after hemorrhagic shock. Shock. 2000;13(Suppl):52.

Lactated Ringer’s, as a resuscitation fluid, yields less acidosis and less coagulopathy than seen with similar volumes of normal saline

·          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.

Normal saline causes a well-recognized metabolic hyperchloremic acidosis; patients resuscitated with lactated Ringer’s do not achieve such levels of acidosis. Furthermore, normal saline-resuscitated patients demonstrate more blood loss than those resuscitated with lactated Ringer’s

·        Kiraly LN, Differding JA, Enomoto TM, Sawai RS, Muller PJ, Diggs B, Tieu BH, Englehart MS, Underwood S, Wiesberg TT, Schreiber MA. 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. discussion 64–5.