4. 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’
5. 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.
6. Sir Leonard Rogers FRS
Successfully used saline in the
treatment of disease while in
India as a military surgeon.
10. Audit Results from 2005ish
What fluid we thought we used
Primary Fluid Used Minor Major Diabetic Emergency
Saline 6 2 15 4
Hartmann's 8 21 7 15
What ever 9 0 0 4
11. Audit Results
What we probably used
Fluid Consultant Trainee Em Lap
Saline 11 9 11
Hartmann's 2 4 2
What ever 0 0 0
12. 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
13. 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
17. 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
18. 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.
19. Does the chloride in saline concern you?
0
5
10
15
20
25
Yes No Yes No
Minor Minor Major Major
Chloride
20. 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)
22. Do the lactate or potassium in Hartmann's
concern you?
0
2
4
6
8
10
12
14
16
18
No Yes
Lactate
Potassium
23. 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
25. 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
26. 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
27. 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
28. 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.
29. 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
31. 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.
32. 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
33. What about the cost
All Hartmann’s
£13,791
All Saline
£12,127
£1664 Less
34. Does audit influence practice?
Hartmans
500
600
700
800
900
1000
1100
July August September October
Hartmans
35. And Finally…
“Saline induced acidosis has a side effect
profile similar to that of ammonium
chloride”
K Gunnerson
Why not repeat this hospital
wide?
Editor's Notes
O’ShaughnessVice president of the royal college of Surgeons was part of a committee set up by the RCS in 1831 in the light of cholera moving across europe.
LattaLeith. Initially tried to replace the fluid PR. The infused ssaline in to an elderly woman in extremis. After 30 minutes and six pints (of saline) the woman announced in a strong voice she was now ‘free from all uneasyness’. Latta left and the woman died six hours later.
The new treatment didn’t really catch on, there was no standarization of the concentration of saline and infection was a major issue. Most clinicians at that time were keen to bleed patietns not fill them up.
Saline was not used again for resusitaiton until Rogers in Calcutta used hypertonic saline successfully in Calcutta to treat cholera.
Ringers solution
Modified Ringer’s solution to treat acidosis in children
(4mos/kg 60 min after infusion finished if 50ml/kg infused over 60 min, returns to normal after another hour)
Sodium down by2mmol/litre, no change in pH
PH down to 7.28, be up to –6.7
Essential in red blood cells as they have no mitochondria.
