Is Lactated Ringer's (LR) or Normal Saline (NS) better for treating sepsis?

From the Guidelines

For sepsis, Lactated Ringer's (LR) solution is generally preferred over Normal Saline (NS) due to its more physiologic electrolyte composition and potential to counteract metabolic acidosis. The recommendation to use LR over NS is based on the most recent and highest quality evidence, which suggests that balanced crystalloids like LR are associated with reduced mortality in critically ill patients, including those with sepsis 1. The Surviving Sepsis Campaign guidelines also support the use of crystalloids as the fluid of choice for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock, with a suggestion to use either balanced crystalloids or saline 1. Some key points to consider when choosing between LR and NS include:

• LR has a more physiologic electrolyte composition that closely resembles human plasma
• LR contains lactate which gets metabolized to bicarbonate, helping to counteract the metabolic acidosis often seen in sepsis
• NS contains higher chloride concentrations which can worsen acidosis and potentially lead to hyperchloremic metabolic acidosis when given in large volumes
• NS administration has also been associated with increased risk of acute kidney injury and greater need for renal replacement therapy compared to balanced crystalloids like LR The typical initial fluid resuscitation in sepsis involves 30 mL/kg of LR given rapidly, followed by additional fluid as needed based on reassessment of the patient's hemodynamic status. While both fluids can effectively expand intravascular volume, the physiologic advantages of LR make it the better choice for most septic patients unless specific contraindications exist, such as severe liver dysfunction (which may impair lactate metabolism) or traumatic brain injury with concern for cerebral edema.

From the Research

Comparison of LR and NS for Sepsis

• The choice between Lactated Ringer's (LR) and Normal Saline (NS) for fluid resuscitation in sepsis patients has been debated, with some studies suggesting that LR may be associated with improved outcomes 2, 3, 4.
• A retrospective analysis of 2022 patients with sepsis found no significant difference in 30-day and in-hospital mortality rates, mechanical ventilation, oxygen therapy, or CRRT requirement between those receiving LR and NS 2.
• Another study of 198 patients with septic shock found that the use of LR was associated with lower blood transfusion requirements and lower incidences of hyperlactacidemia and hyperchloremia, but no significant difference in 28-day mortality rate 3.
• A secondary analysis of the CLOVERS trial found that initial fluid resuscitation with LR was associated with improved survival and more hospital-free days at 28 days compared to NS 4.
• However, other studies have noted that the evidence is limited and that the choice of fluid may depend on individual patient factors and clinical context 5, 6.

Key Findings

• LR may be associated with improved outcomes in sepsis patients, including lower mortality rates and more hospital-free days 4.
• NS may be associated with higher incidences of hyperlactacidemia and hyperchloremia 3.
• The choice of fluid may depend on individual patient factors and clinical context 5, 6.
• Further research is needed to solidify the current guidelines on the use of balanced crystalloids in sepsis patients 2, 6.

Fluid Resuscitation in Sepsis

• Intravenous fluid resuscitation is a key component of the initial resuscitation of septic shock 6.
• International consensus guidelines suggest the administration of at least 30mL/kg of isotonic crystalloid fluid 6.
• However, there is a paucity of high-level evidence to support this strategy, and some studies have found that a large positive fluid balance is associated with worse outcomes 6.