liver failure and LR

athomas91 · Jan 11, 2004

i haven't looked this up... distant memory going here.....

but the lactate byproducts can make an acidotic state worse.....????

javajunkie · Jan 11, 2004

I learned that you shouldn't give LR to patients with hepatic failure because it will cause metabolic acidosis. The reasoning is that in normal people, the lactate combines with H+ ions to form lactic acid which is then metabolized by the liver into HCO3. So LR works as a buffer in normal liver function but not so much in liver failure. Hope this helps :)

Noney · Jan 11, 2004

Wow, I had completely forgotten about this. Amazing the things you forget.

Noney

CRHSrn · Jan 12, 2004

thanks, this helps a lot. i knew there was something to it ... just couldn't remember quite what it was. i just remember that annoying woman who gives the CCRN lectures saying that she 'saved a Dr's license' b/c she refused to give LR to a pt in liver failure

nursepenny · Jan 12, 2004

Thank you so much for this thread. This is something I did not know. My daughter has an undetermined liver disease w/fibrosis. The thought is, she has auto-immune hepatitis, but has not yet been diagnosed. Liver biopsy said she had significant fibrosis consistent w/ cirrohsis, but does not have cirrohsis. Has extremely elevated enzymes, has never drank alcohol, never taken any drugs, or smoked.

But anyway, I will remember this in case she is hospitalized and LR is ordered. Thanks again. I learn so much from this site, every day.

Tenesma · Jan 13, 2004

i think there are a lot of misconceptions about lactic acidosis associated with lactated ringers... while you are right that in hepatic failure there is no/minimal conversion of lactate to bicarbonate, you can't imply that it would cause or worsen lactic acidosis. You might have higher measurable lactate levels, but in of itself that number means nothing unless it is associated with ischemia, in which case that number is not diagnostic but purely a prognostic value (ie: a high lactate - ONLY in the setting of presumed ischemia - would suggest a higher mortality rate).

Your body produces an excess of about 20 mmols/kg/day of Lactate which is about 1500 mmols per day (which is a far cry from the 28mmols/Liter of LR) ... the implication that all of a sudden that LR would cause a lactic acidosis is a common myth propagated in the nursing literature and has no true evidence to back it up. For example in patients with chronic hepatic/end-stage liver disease, why aren't they all in lactic acidosis??? because their muscle picks it up and converts into sugar and the kidney excretes it.... the times that you see true lactic acidosis in the end-stage liver population is when they are in septic shock, have acute renal dysfunction. So you would then argue not to give LR to an end-stage liver patient with hepato-renal syndrome - well, those patients should be on CVVH or dialysis and that would mean that you could give LR since the dialysis/filtration will assist with management of the acidosis - and in the setting of sepsis they need volume and it doesn't matter at this point whether they get LR or saline....

So my point is: you can use LR for patients with hepatic dysfunction.

athomas91 · Jan 13, 2004

Tenesma - thank you for your post - i look forward to the day when i will have all that info...

i guess my question is - i know that LR isn't going to cause a sudden state of acidosis...but if someone were in such a state - why WOULD you give it -even though the chances are minimal it would exacerbate it??

mittels · Jan 13, 2004

Try thinking K+, look at the bag, see what LR consists of.

Tenesma · Jan 13, 2004

mittels what is your point about the K??? and what does that have to do with liver failure?

mittels · Jan 13, 2004

Originally posted by Tenesma
mittels what is your point about the K??? and what does that have to do with liver failure?

Critical thinking now!!!!

K+ and glucose in LR where does K+ metabolize?

Metabolic acidosis with compensation

athomas91 · Jan 13, 2004

i am fully aware of what substances LR consists of.....my point is if there are better fluids out there to use, why would LR be used in that scenario....

and.... in an acidotic state - the K+ will be more attracted to the negative vibe extracellularly thereby moving out of the intracellular space - causing a false elevation of K+ (such as happens in DKA) - so why in the world would you give an infusion of RL which could exacerbate this "false" hyperkalemia??