Intravenous saline has been a go-to for physicians since 30 years before the Civil War started. Emergency physician and intensivist Nicholas Johnson, MD, of University of Washington’s Harborview Medical Center in Seattle, thinks it’s about time that changed.

So his ACEP19 session, “The Death of Normal Saline: IV Fluids in 2019,” was an impassioned sales pitch on the value of using balanced fluids such as Lactated Ringer’s.

“There’s no difference in cost, there’s definitely no harm in using balanced solutions and there’s a fairly large and growing body of data showing that saline is associated with lots of different types of harms,” Dr. Johnson said. “Metabolic abnormalities, acute kidney injury and maybe even mortality… all of the data is sort of pointing us in one direction.”

Dr. Johnson’s talk focused on last year’s SMART trial, from Vanderbilt University Medical Center in Nashville, Tennessee. The review found rates of major kidney events at 30 days out were roughly 1% lower with balanced crystalloids versus saline. A companion study of non-critically ill patients showed similar results.

“People have looked at this trial and come away with two different conclusions, depending on their prior beliefs,” Dr. Johnson said. “Some people said, ‘A 1% difference in positive outcomes?  Big deal. Is this really something that should be practice changing?’ And other people have said it’s really hard to conduct a critical-care trial that shows any difference – so any difference in meaningful.”

Dr. Johnson, clearly in the latter camp, said there are cases where saline may be better than a balanced solution, including patients where drug compatibility is a concern or potential issues with brain injuries or hyperkalemia. He also noted that given the dichotomous views on the efficacy of balanced solutions, he doesn’t expect emergency physicians to abandon saline en masse.

Still, given his views on the benefits of balanced solutions including Lactated Ringer’s and Plasma-Lyte A, Dr. Jonhson suggests practice changes to encourage their use. The bedside carts he uses have been reorganized to put Lactated Ringer’s on top of saline, so physicians don’t just reach for saline out of routine. In addition, all of the department’s word sets have been updated to put balanced solutions over saline.

“At least among the group that I work with, this is something that evolved over many ears and eventually the culture changes,” Dr. Johnson said. “But culture change is hard. We can make it easier for people by changing how things are stored in the hospital and changing how things are listed on the electronic medical record. And those have been shown to change behavior in various ways, but culture change is one of the hardest things that we do in medicine.”