The intravenous volume resuscitation is one of the preferred first-line live-saving techniques among patients with hemodynamic instability in the emergency department. The medication mediates against a decreased volume of circulation fluids that result from many causes that includes vomiting, bleeding, diarrhea, and dehydration. The subject, however, raises a lot of debate concerning the choice of fluid. The available options of fluids include; blood, colloid solutions, blood substitutes and crystalloid solutions (Elbers & Gatz, 2012). Even though, Colloids and crystalloid attracts the most controversy and attention. Crystalloids are popular because of their long time in service of more than 110 years as opposed to colloids that came on the market around the Second World (1939-1945) War (Santi et al., 2015). Majority of the researchers encourages the use of colloids during emergency resuscitation though research proves that crystalloids are used widely as noted by Lira and Pinsky, (2014). Other researchers debate on the actual crystalloid to use. They compare the normal saline 0.9% solution with balanced salts such as the Hartmann's solution. Some of the factors they consider in the discussion of choice between the fluids include; their cost, interaction with CO-infusions of blood products, shelf life, and indication for using the fluid. This paper focuses on a discussion between the choice of two crystalloids; the normal saline 0.9% and Hartmann’s solution. It discusses which is better based on their composition, effects of their differences of composition, and cost during the resuscitation on patients in the emergency department.
According to Honore, Jacobs and Spapen, (2016), the normal saline solution has been the number one choice in resuscitation during emergency cases. Some of the early drivers for its preference over other balanced salt crystalloids such as Hartmann's solution based on cost. The price variation motivation to prefer normal saline solution based on its near half price as compared to the Hartmann's solution. However, in emergency cases, the cost of the fluid is not a major driving factor as compared its effectiveness because the daily cost of maintaining a patient in an emergency department is in thousands of dollars per day as compared to the less than one hundred dollars of the fluid. Furthermore, with the increased discovery of balanced crystalloids, the cost of the Hartmann's solution and Normal saline 0.9% converge at around one U.S.A. dollar per liter packet (Semler & Rice, 2016). It, therefore, rules out the factor of cost in the choice of which solution one has to use in emergency department.
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The fluid composition is one of the major starting points of their comparison. Normal saline 0.9% is composed of sodium ions (Na + ) and chloride ions (Cl - ). The concentration of the individual ions is 154 millimoles per liter (mmol/L) for both potassium and chloride. The equality of the concentration of the two ions gives it its name of “normal” that should not be confused with the normality in reference to the constitution of plasma (Zayed et al., 2018). The ion concentration makes Normal saline solution isotonic as compared to plasma as noted by Elbers & Gatz, (2012). The composition of Normal saline 0.9%, makes it be both hyperchloremic and hypernatremia relative to plasma.
The Hartmann's solution, on the other hand, contains sodium ions (Na + ), chloride ions (Cl - ), potassium ions (K + ), and Lactate. The concentration of the various solutes is 131mmol/L for sodium (Na + ), 111mmol/L for chloride (Cl - ), 5mmol/L for potassium and 29mmol/L for lactate. Its composition makes it a buffered saline fluid that is isotonic compared to plasma (Leach, & Leach, 2009) . The two fluids compare to the solutes concentration of plasma as follows: it contains 140mmol/L of Sodium ions (Na + ), 103mmol/L of chloride ions (Cl-) , 4-5 mmol/L of potassium ions (K + ), 2.2-2.6mmol/L of calcium ions (Ca 2+ ), 23-26mmol/L of bicarbonate (HCO 3- ), and 24mmol/L of buffer concentration (Hoorn, 2016). The osmolarity of the three fluids, therefore, compares as flows; plasma has between 286 milliosmoles per liter (mOsm/L) and 308 mOsm/L as compared to 308 mOsm/L of Normal saline 0.9% and 278 mOsm/L for the Hartmann's solution, respectively (Hoorn, 2016).
From the analysis of the fluids' constitution, it is evident that there is a significant difference in their constitution. Whereas normal saline contains only sodium and chloride ions, the Hartmann's solution contains potassium and lactate in addition to the two ions. The difference brings significant points of discussion and analysis on the effects it presents when administrated to the patients in the emergency section during resuscitation as noted by Choosakul, Harinwan, Chirapongsathorn & Puttapitakpong, (2017).
The presence of potassium in the Hartmann's solution and its absence is the normal saline solution is the first point of concern. The Potassium ions (K + ) that are present in the Hartmann's solution are contraindicated in intravenous administration on hyperkalemia patients. However, a Hartmann's solution contains no more than 5mmols/L of potassium ions (K + ) (Vincent, 2009). The low concentrated is easily diluted after administration by the extracellular fluids. The ions can only be contraindicated in patients with kidney injury as discussed by Santi et al., (2015). The normal saline solution on the other side has no potassium ions although it is known to mobilize the intracellular potassium ions (K + ) that sometimes cause hyperchloremic acidosis after its administration to patients. The increased acidosis and renal injury associated with the mobilization of potassium ions (Schreiber, 2011).
The high concentration of chloride ions (Cl - ) of 154mmol/L in the normal saline 0.9% solution as compared to the 111mmol/L in Hartmann's solution is another point of consideration. The variation brings about differences in the renal function and the acid-base balance. Although the difference is small, adverse effect of higher concentration of the chloride ions (Cl - ) manifested more in cases that administer the normal saline solution as compared to the Hartmann's solution (Lira & Pinsky, 2014). The presence of the chloride ions (Cl - ) and the absence of carbonates (HCO 3- ) or anions that can metabolize into carbonates cause saline-induced acidosis. Research indicates that there is a more likelihood of patients under intensive care, including emergency cases to develop the conditions as opposed to patients in other stable condition. Induced saline acidosis can also be severe in patients with a damaged kidney and also impairs the renal function as discussed by Semler & Rice, (2016). The problems of high rate infusion in emergency resuscitation should resolve within the next few days as noted by Choosakul, Harinwan, Chirapongsathorn & Puttapitakpong, (2017); although Semler & Rice, (2016) argues that the patient might require dialysis and it leads to acute kidney injury. Finally, the high content of chloride ions can also cause severe kidney injury as confirmed by Semler & Rice, (2016). The high concentration of the chloride ions reduces the proximal tubular re-absorption in the kidney's loop of Henle. As such, the kidney retains more sodium ions due to the reduced glomerular filtration rate. It causes the formation of urine to reduce and retention of sodium in the kidney.
The presence of lactate in Hartmann's solution and its absence is normal saline 0.9% solution, is another factor for consideration. The presence of lactate in the Hartmann's solution and its absence in the Normal saline solution makes the Hartmann's solution a closer mimic of plasma (Weinberg et al., 2017). The closeness reduces the variations in ion concentration and the overall adverse reaction of the body. However, lactate undergoes metabolism to produce sugar; a process called gluconeogenesis (Choosakul, Harinwan, Chirapongsathorn & Puttapitakpong, 2017). It is therefore restricted for patients with diabetes Tseng, (2019) notes. Additionally, its administration is likely to confound the understanding that it is a biomarker of tissue oxygenation. Semler & Rice, (2016) also notes that researchers have postulated that Hartmann's solution may cause hyperlactatemia though there is no evidence gathered from the clinical trial and not particular research has narrowed to prove it. Nonetheless, its presence is clinically significant over its absence in Normal saline 0.9% in the prevention of saline acidosis.
Studies have indicated that a massive infusion of normal saline 0.9% leads to hyperchloremic metabolic acidosis, renal vasoconstriction, and hypernatremia (Trujillo-Zea, Aristizábal-Henao & Fonseca-Ruiz, 2015). As such, it suits patients with the propensity of developing hypernatremia, metabolic alkalosis and hypochloremia that are common in patients that vomit (Miclescu, Sharma & Wiklund, 2013). It is however not recommended in patients with existing acidosis or renal complication making the Hartmann's solution the preferred fluid (Urbano et al., 2012). Similarly, Choosakul, Harinwan, Chirapongsathorn & Puttapitakpong, (2017) also notes that Normal saline 0.9% is preferable over the Hartmann's solution in diabetic cases. Other contraindications of Hartmann's solution include patients that have hyperhydration (too much fluid), hyperkalemia (too much potassium (K + ) in the blood, hypercalcemia (too much calcium (Ca 2+ ) in the blood) and metabolic alkalosis (too much alkali in the blood) (Semler & Rice, 2016).
Based on the discussion, the two fluids are appropriate in the emergency department. The primary guiding principle on the choice of which fluid to choose over the other is the unique condition of the patients. It is evident that some of the unique conditions to look for include diabetic cases, cases with damaged kidney and the renal system, and vomiting cases. Given that the patient has no special requirements it is, however, to correct to state that the Hartmann's solution is better than the Normal saline 0.9% solution. The Hartmann's solution reduces the chance of the patients developing saline acidosis which is prevalent in patients in the emergency department as ( Mohamad, & UoM, 2012) concur.
In conclusion, this paper focuses on a discussion between the choice of two crystalloids; the normal saline 0.9% and Hartmann’s solution. It discusses which is better based on their composition, effects of their differences of composition, cost, and co-infusion during the resuscitation on patients in the emergency department. From the discussion, the constitution of the Hartmann's solution and normal saline solution 0.9% varies. The variation of their solutes composition and concentration makes each fluid preferable in particular types of patients. For instance, the Hartmann's solution has potassium ions (K + ), lactate, and a lesser concentration of chloride ions (Cl - ) as compared to the normal saline 0.9%. The presence of potassium ions has no significant variation. However, the chloride ions in the normal saline 0.9% solution increase its prevalence to cause saline acidosis and kidney damage caused by retained sodium ions (Na + ). The presence of Lactate in the Hartmann's solution, on the other hand, increase the sugar level in the circulating blood hence contraindicated in patients with diabetes and hyperlactatemia. Cost is not a significant factor given that the priority of the emergency department is saving lives. Nonetheless, the prices of the two fluids converge at the rate of one dollar per one-liter packet. Though variations influence the choice between the two fluids, it depends on the condition of the patient. However, if the patient has no contraindication against the Hartmann's solution, it is preferred because most patients in the emergency department are prevalent to saline acidosis.
References
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