Why can't patients with mitochondrial disease have lactated Ringer's (Lactated Ringer's solution)?

Lactated Ringer's Should Be Avoided in Patients with Mitochondrial Disease Due to Risk of Lactic Acidosis

Patients with mitochondrial disease should not receive Lactated Ringer's solution due to their inherent tendency to develop lactic acidosis, which can be exacerbated by the lactate content in the solution. 1

Pathophysiology and Rationale

Patients with mitochondrial disease have impaired oxidative phosphorylation and dysfunctional electron transport chains, which leads to:

• Baseline tendency toward lactic acidosis
• Compromised ability to metabolize exogenous lactate
• Increased risk of metabolic decompensation during periods of stress (including surgery)

The lactate in Lactated Ringer's solution (28 mmol/L) could potentially:

• Add to the already elevated lactate levels in these patients
• Worsen existing metabolic acidosis
• Trigger metabolic decompensation during periods of physiologic stress

Recommended Fluid Management for Mitochondrial Disease

Preferred Fluids:

• First choice: Lactate-free crystalloids such as 5% dextrose-0.9% saline 1
• Normal saline (0.9% NaCl) for maintenance and resuscitation

Timing of IV Fluid Administration:

• Begin IV fluids during preoperative fasting period
• Continue throughout perioperative period
• Maintain normoglycemia to prevent excessive glycolytic oxidation of glucose (which increases plasma lactate)

Special Considerations

Perioperative Management:

• Meticulous individual assessment is essential due to diverse nature of mitochondrial disease
• Careful attention to fluid management is critical
• Avoid prolonged fasting which may exacerbate lactic acidosis
• Monitor for signs of metabolic decompensation

High-Risk Patients:

• Patients with Leigh's disease appear to be at greater risk after general anesthesia
• Those with more severe clinical disease require extra vigilance
• Patients with documented variable respiratory drive need special attention

Common Pitfalls and Caveats

1. Don't assume all mitochondrial disorders are the same: The severity and specific metabolic defects vary widely among patients with mitochondrial disease.

2. Don't rely on Lactated Ringer's in emergency situations: Even in resuscitation scenarios where Lactated Ringer's might typically be preferred over normal saline, patients with mitochondrial disease should still receive lactate-free solutions.

3. Don't confuse mitochondrial disease with other metabolic disorders: While some organic acidurias may tolerate Lactated Ringer's 2, mitochondrial disease specifically requires avoidance of lactate-containing fluids.

4. Monitor for metabolic decompensation: Patients with mitochondrial disease are at risk for metabolic decompensation during periods of stress, which can be exacerbated by inappropriate fluid management.

By adhering to these guidelines and using lactate-free IV fluids in patients with mitochondrial disease, clinicians can help prevent worsening lactic acidosis and reduce the risk of metabolic decompensation, thereby improving patient outcomes.