(1413) Resuscitative Intravenous Fluid Type and Association With Lactate Clearance

Introduction: Intravenous fluids (IVF) are widely utilized in emergency departments (ED) and Intensive Care Units (ICUs) to aid in resuscitation and the two most common types are lactated Ringer’s (LR) and normal saline (NS). In patients presenting with elevated serum lactate levels, there remains a paucity of data on the association between these two fluid types and lactate clearance.

Methods: We conducted a secondary analysis of a large hybrid implementation and effectiveness study involving 22 hospitals in Idaho and Utah between November 2018 and February 2020. The intervention involved combining electronic order set modifications and alerts, and sequential clinical education to encourage prescribing of lactated Ringer’s. Inclusion criteria for this sub-analysis were ED patients that had an initial lactate of 2 mmol/L or greater, were administered IVFs and had a second lactate drawn between 30 minutes and 24 hours later. We conducted linear regression analysis with covariates of patient demographics, presenting vital signs, symptoms and comorbidities to assess the change in serial lactate levels within and between each implementation period.

Results: Our analysis included 2,761 patients, 1,543 in the pre-implementation cohort and 1,218 in the post-implementation cohort. During the pre-implementation period, NS accounted for median [interquartile range (IQR)] 90% (50%-100%) of the IVF prescribed and only 9% (0%-42%) post-implementation. Median (IQR) for LR was 0% (0%-43%) and 89% (50%-99%) for the same respective time periods. A median of 3,000 mL (IQR, 2,000-5,546mL) of IVF were administered and median time between lactate levels was 2.57 hours (1.85-3.68). Pre-implementation the median first measured lactate was 2.8 (IQR, 2.3-3.7) and second median lactate was 3.0 (2.4-4.2). Post-implementation the respective values were 2.8 (2.3-3.7) and 3.0 (2.4-4.4). The difference between the change in rise of lactate levels was observed to not be statistically significant (Mann-Whitney U, p-value=0.761).

Conclusions: Following this multifaceted implementation encouraging lactated Ringer’s use within a large integrated healthcare system, we observed a significant increase in the proportion of IVF that was LR and no association with lactate clearance.