Thank you for your attention and article on the recent discussion regarding LR versus NS [“Myth: Normal Saline is the IV Fluid of Choice,” April 2018]. Admittedly, I have not performed as extensive an investigation and review of the literature as you, but in my current opinion, although more evidence is forthcoming and trending in favor of LR over NS, there are four factors that merit attention and some disclosure as practice and logistics evolve.

1. Overall evidence is still modestly limited and investigated in select populations/clinical data point(s)—without necessarily incorporating other parts of care delivery (see #4).
2. Difference/benefit as well as harm may not be as pertinent and clinically relevant to the majority of ED patients.
3. Manufacturing cost difference, albeit modest, exists, and I am not sure if, additionally, hospitals charge differently for LR and NS.
4. Multiple medications, more than with NS, are not compatible for administration with LR, including some administered frequently to ED patients, including antibiotics, analgesics, hematologic agents, steroids, and ACLS/code meds. 

For individual and select patients, #4 could be problematic if personnel are not sufficiently aware, and #1, #2, and #3 may not outweigh the potential benefits. With time, #1, #3, and #4 can change, but for now, when taking the specialty/entire ED population, it may not be prudent to readily discount #2 and #3.

Christopher S. Kang, MD, FACEP, FAWM
Tacoma, Washington