What is the role of lactated Ringer's (LR) solution in the correction of ketoacidosis?

Role of Lactated Ringer's Solution in the Correction of Ketoacidosis

Lactated Ringer's solution is superior to normal saline for the correction of ketoacidosis, as it leads to faster resolution of high anion gap metabolic acidosis and avoids iatrogenic hyperchloremic acidosis.

Mechanism and Benefits of Lactated Ringer's

Lactated Ringer's solution (also known as Hartmann's solution) offers several advantages in ketoacidosis management:

• Contains lactate that is metabolized into bicarbonate, helping to correct metabolic acidosis 1
• Has a sodium concentration (130-131 mEq/L) and osmolality (273-279 mOsm/L) closer to plasma than normal saline 1
• Reduces the risk of iatrogenic hyperchloremic acidosis that commonly occurs with large-volume normal saline administration 2

Evidence Supporting Lactated Ringer's in Ketoacidosis

Recent research strongly supports the use of balanced crystalloids like Lactated Ringer's:

• A 2024 multicenter study demonstrated that Lactated Ringer's was associated with significantly faster resolution of high anion gap metabolic acidosis compared to normal saline in diabetic ketoacidosis (adjusted hazard ratio 1.325; 95% CI 1.121-1.566; p < 0.001) 3
• Another 2024 study showed reduced time to DKA resolution (17.1 vs 20.6 hours, p = 0.02) and shorter duration of insulin infusion (16.0 vs 21.4 hours, p < 0.001) with Lactated Ringer's compared to normal saline 4
• A 2022 study found significantly lower incidence of iatrogenic hyperchloremia with Lactated Ringer's versus normal saline (64.2% vs 74.4%, p = 0.05) and better renal recovery at 48 hours (mean change in serum creatinine: -0.15 mg/dL vs -0.04 mg/dL, p = 0.002) 2

Clinical Application in Different Types of Ketoacidosis

Diabetic Ketoacidosis

• Use Lactated Ringer's as the primary crystalloid for fluid resuscitation 3
• For severe dehydration, administer isotonic intravenous fluids until pulse, perfusion, and mental status normalize 5
• Continue with oral rehydration solution once the patient is stabilized 5

Non-diabetic Ketoacidosis

• Lactated Ringer's has been successfully used to treat ketoacidosis in non-diabetic conditions, such as ketogenic diet-induced ketoacidosis 6
• Combine with dextrose 5% solution when glucose levels are normal or low 6

Special Considerations and Contraindications

Despite its benefits, Lactated Ringer's is not appropriate in all clinical scenarios:

• Avoid in traumatic brain injury: Hypotonic solutions like Lactated Ringer's should be avoided in patients with severe head trauma to prevent cerebral edema 5, 1
• Caution in liver failure: Metabolism of lactate may be compromised in severe liver disease 1
• Monitoring requirements: Regular assessment of electrolytes, especially chloride and sodium levels, is essential during treatment 2

Fluid Management Protocol for Ketoacidosis

1. Initial resuscitation: Administer Lactated Ringer's at 15-20 mL/kg in the first hour 5
2. Ongoing fluid therapy: Continue with Lactated Ringer's based on clinical response and laboratory parameters
3. Electrolyte monitoring: Check electrolytes every 2-4 hours during active treatment
4. Transition to oral hydration: Once the patient is stabilized, transition to oral rehydration solution 5

Conclusion from Latest Evidence

The most recent and highest quality evidence demonstrates that Lactated Ringer's solution offers significant advantages over normal saline in the management of ketoacidosis, including faster resolution of acidosis, reduced hyperchloremia, and better renal outcomes. While older studies showed mixed results 7, the newest research consistently supports the use of balanced crystalloids in this setting 3, 4, 2.