0.9% NaCl (Normal Saline) – Perhaps not so normal after all?

Abstract

Crystalloid infusion is widely employed in patient care for volume replacement and resuscitation. In the United States the crystalloid of choice is often normal saline. Surgeons and anesthesiologists have long preferred buffered solutions such as Ringer's Lactate and Plasma-Lyte A. Normal saline is the solution most widely employed in medical and pediatric care, as well as in hematology and transfusion medicine. However, there is growing concern that normal saline is more toxic than balanced, buffered crystalloids such as Plasma-Lyte and Lactated Ringer's. Normal saline is the only solution recommended for red cell washing, administration and salvage in the USA, but Plasma-Lyte A is also FDA approved for these purposes. Lactated Ringer's has been traditionally avoided in these applications due to concerns over clotting, but existing research suggests this is not likely a problem. In animal models and clinical studies in various settings, normal saline can cause metabolic acidosis, vascular and renal function changes, as well as abdominal pain in comparison with balanced crystalloids. The one extant randomized trial suggests that in very small volumes (2 l or less) normal saline is not more toxic than other crystalloids. Recent evidence suggests that normal saline causes substantially more in vitro hemolysis than Plasma-Lyte A and similar solutions during short term storage (24 hours) after washing or intraoperative salvage. There are now abundant data to raise concerns as to whether normal saline is the safest replacement solution in infusion therapy, red cell washing and salvage, apheresis and similar uses. In the USA, Plasma-Lyte A is also FDA approved for use with blood components and is likely a safer solution for these purposes. Its only disadvantage is a higher cost. Additional studies of the safety of normal saline for virtually all current clinical uses are needed. It seems likely that normal saline will eventually be abandoned in favor of safer, more physiologic crystalloid solutions in the coming years.

Reflection on passive immunotherapy in those who need most: some novel strategic arguments for obtaining safer therapeutic plasma or autologous antibodies from recovered COVID‐19 infected patients

“…This article is protected by copyright. All rights reserved for clinical use as previously reported by our group (Blumberg N et al, 2018). The collected washed solution can then later sterilized in special blood packages obtainable from a biotech company, which can be used in some well-established means for their sterilization and pathogen reduction by the UVC.…”

In silico model of the dilutional effects of conventional component therapy versus whole blood in the management of massively bleeding adult trauma patients

“…1 However, the acidic nature of "normal" saline had not been appreciated and the potentially beneficial effect of permissive hypotension was not widely practiced. [2][3][4] More recently, an increasing body of evidence has demonstrated that aggressive resuscitation with crystalloid fluids might actually be detrimental to trauma patients, [5][6][7][8][9][10][11][12] and so modern trauma resuscitation protocols minimize their use.…”

“…In silico model of the dilutional effects of conventional component therapy versus whole blood in the management of massively bleeding adult trauma patients Jansen N. Seheult ,1,2 Michelle N. Stram, 1 Jason Sperry, 3,4 Philip C. Spinella, 5 Darrell J. Triulzi, 1,2 and Mark H. Yazer 1,2 BACKGROUND: There are multiple approaches to the blood product and fluid resuscitation of a bleeding trauma patient. An in silico model of different trauma resuscitation strategies was constructed to predict their effects on the volumes of the different body fluid compartments and on several important hemostatic factors.…”

Sickle red blood cells are more susceptible to in vitro haemolysis when exposed to normal saline versus Plasma‐Lyte A

“…Its virtues include long clinical experience and low cost compared with buffered crystalloid solutions or albumin. However, there are now serious concerns about the safety of normal saline . It contains strikingly higher quantities of chloride and is relatively acidic, which predisposes to hyperchloremic metabolic acidosis in some patients .…”

“…It contains strikingly higher quantities of chloride and is relatively acidic, which predisposes to hyperchloremic metabolic acidosis in some patients . It is unbuffered and hypertonic compared with the electrolyte composition of plasma and other solutions .…”