Saline vs Hartmann’s SolutionThe debate

Dr J Groves

Q. What is this?

A. vibrieo cholerae

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’

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.

Sir Leonard Rogers FRS

Successfully used saline in the treatment of disease while in India as a military surgeon.

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.

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

Does the nature of the fluid matter?

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

Audit ResultsWhat we probably used

Fluid Consultant Trainee Em Lap

Saline 11 9 11Hartmann's 2 4 2What ever 0 0 0

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

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

Most Popular Fluid?

Fluid usage in theatres

02000400060008000

10000120001400016000

2004-2005

2005-2006

2006-2007

Lit

res

Saline l

saline .5l

Hartmans l

Hartmans 0.5l

Disadvantages of Hartmann’s

• Neonates

• Neurosurgery– Hartmann’s mildly decreases serum osmolality– Decreases serum sodium

• Lactate

• Marginally more expensive (6p/litre)

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

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.

Does the chloride in saline concern you?

0

5

10

15

20

25

Yes No Yes No

Minor Minor Major Major

Chloride

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)

You Haven’t mentioned the Lactate or Potassium

Do the lactate or potassium in Hartmann's concern you?

0

24

68

1012

1416

18

No Yes

Lactate

Potassium

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

Cori Cycle

(Diagram from Leeds dental school)

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

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

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

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.

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

Primary fluid used

0

5

10

15

20

25

Minor Major Diabetic Emergency

Saline

Hartmann's

What ever

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.

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

What about the cost

All Hartmann’s

£13,791

All Saline

£12,127

£1664 Less

Does audit influence practice?

Hartmans

500

600

700

800

900

1000

1100

July August September October

Hartmans

And Finally…

“Saline induced acidosis has a side effect profile similar to that of ammonium

chloride”

K Gunnerson

Why not repeat this hospital wide?