What is Lactated Ringer's (Lactated Ringer's solution)?

From the Guidelines

Lactated Ringer's solution is the preferred choice for fluid resuscitation in most clinical settings, including acute pancreatitis, due to its isotonic composition and lower risk of hyperchloremic metabolic acidosis compared to normal saline 1.

Key Characteristics of Lactated Ringer's Solution

• It contains sodium chloride, potassium chloride, calcium chloride, and sodium lactate in water, making it isotonic to human plasma.
• The lactate component is metabolized by the liver to bicarbonate, helping to correct metabolic acidosis.
• The typical administration rate varies based on clinical need, ranging from maintenance rates of 1-2 mL/kg/hr to bolus infusions of 20 mL/kg for hypovolemic patients.

Clinical Considerations

• Lactated Ringer's is generally safer than normal saline for large volume resuscitation as it causes less hyperchloremic metabolic acidosis 1.
• However, Lactated Ringer's should be used cautiously in patients with:
  • Severe liver disease (who cannot metabolize lactate effectively) 1.
  • Hyperkalemia (due to its potassium content).
  • Severe metabolic alkalosis.
• It's also not ideal for mixing with blood products due to the calcium content which can cause clotting.

Evidence-Based Recommendations

• A recent systematic review and meta-analysis found that aggressive intravenous hydration with lactated Ringer's solution did not reduce mortality in acute pancreatitis, and may even increase the risk of fluid overload and mortality in non-severe cases 1.
• Another study found that balanced crystalloids, such as lactated Ringer's, decreased mortality more than hydroxyethyl starch and saline in patients with sepsis 1.
• The largest RCT to date found no difference in mortality or AKI in critically ill adults receiving lactated Ringer's or saline, but an updated meta-analysis concluded that using balanced crystalloids is associated with reduced mortality in the general population of critically ill patients without cirrhosis 1.

From the Research

Lactated Ringer's Solution Overview

• Lactated Ringer's (LR) solution is a type of crystalloid fluid used for resuscitation and fluid replacement in various medical conditions, including acute pancreatitis, sepsis-induced hypotension, and renal transplantation 2, 3, 4, 5.
• The solution contains electrolytes such as sodium, potassium, calcium, and lactate, which help to maintain fluid balance and electrolyte homeostasis in the body.

Comparison with Normal Saline

• Studies have compared the use of LR solution with normal saline (0.9% NaCl) in various clinical settings, including renal transplantation and sepsis-induced hypotension 3, 5.
• The results suggest that LR solution may be associated with improved outcomes, such as reduced hyperkalemia and metabolic acidosis, compared to normal saline 3, 5.

Safety and Efficacy

• The safety and efficacy of LR solution have been evaluated in patients with reduced kidney function, and the results suggest that it is not independently associated with the development of hyperkalemia in these patients 2.
• However, another study found that the use of LR solution did not eliminate the risk of strong ion difference-related metabolic acidosis following on-pump cardiac surgery 6.

Clinical Applications

• LR solution has been used as an initial resuscitation fluid in patients with acute pancreatitis, and the results suggest that it may be associated with reduced 1-year mortality compared to normal saline 4.
• It has also been used in patients with sepsis-induced hypotension, and the results suggest that it may be associated with improved survival and more hospital-free days at 28 days compared to normal saline 5.