How to manage a patient with hypotension using lactated Ringer's (LR)?

From the Guidelines

For a patient with hypotension, a single bolus of 500cc Lactated Ringer's (LR) is a reasonable initial step, but it should be followed by reassessment and potentially further fluid administration or other interventions as needed, according to the most recent and highest quality evidence available 1.

Key Considerations

• The initial management of hypotension involves assessing the patient's volume status and perfusion, with the use of hemodynamic monitoring tools to guide fluid resuscitation 1.
• Lactated Ringer's is recommended for fluid administration due to its balanced electrolyte composition, which closely resembles plasma, making it physiologically compatible 1.
• The goal of fluid resuscitation is to optimize volume status and improve perfusion, with targets including a mean arterial pressure (MAP) of at least 65 mmHg and urine output of at least 0.5 mL/kg/hour 1.
• Patients with severe hypotension unresponsive to initial fluid resuscitation may require vasopressors, such as norepinephrine, in addition to continued fluid therapy 1.

Monitoring and Adjustments

• Close monitoring of vital signs, urine output, mental status, and skin perfusion is essential during resuscitation, with adjustments made as needed to avoid fluid overload or under-resuscitation 1.
• The use of large-bore IV access (18G or larger) can facilitate rapid infusion of fluids, and invasive hemodynamic monitoring may be necessary in some cases to guide therapy 1.

Special Considerations

• In patients with cardiac or renal dysfunction, more cautious fluid administration with closer monitoring is necessary to prevent volume overload 1.
• The choice of fluid and the approach to resuscitation may need to be tailored to the individual patient's underlying condition and response to therapy 1.

From the Research

Management of Hypotension with Lactated Ringer's

To manage a patient with hypotension using lactated Ringer's (LR), the following steps can be considered:

• Administer a bolus of LR solution to help increase blood pressure and improve cardiac output 2
• The amount of LR solution to be administered can vary depending on the patient's condition, but a common dose is 500cc 3
• It is essential to monitor the patient's vital signs, including blood pressure, heart rate, and oxygen saturation, during and after the administration of LR solution
• If the patient's condition does not improve with the initial bolus, additional doses of LR solution may be necessary, or other interventions such as vasopressors or blood transfusions may be considered

Comparison with Normal Saline

Studies have compared the use of LR solution with normal saline for fluid resuscitation in patients with hypotension:

• One study found that initial fluid resuscitation with LR solution compared with 0.9% saline might be associated with improved survival in patients with sepsis-induced hypotension 4
• Another study found that early resuscitation of hemorrhagic shock with LR solution had more favorable effects than normal saline on extravascular lung water, pH, and blood pressure, but not on oxygenation 5
• However, a crossover trial found that a hospital-wide policy to administer LR solution rather than normal saline did not result in a significantly lower incidence of death or readmission to the hospital within 90 days after the index admission 6

Key Considerations

When using LR solution to manage hypotension, it is crucial to consider the following:

• The patient's underlying condition and the cause of hypotension
• The potential risks and benefits of LR solution, including the risk of fluid overload and electrolyte imbalances
• The need for ongoing monitoring and adjustment of treatment as necessary
• The potential interactions with other medications or interventions, such as vasopressors or blood transfusions 3, 4, 5, 2, 6