What are the indications for Ringer lactate (lactated Ringer's solution)?

Indications for Lactated Ringer's Solution

Lactated Ringer's solution is indicated as a first-line crystalloid fluid for initial resuscitation in hypotensive bleeding trauma patients without severe traumatic brain injury, burn management, and sepsis-induced hypotension.

Primary Indications

Trauma Resuscitation

• Indicated for initial fluid therapy in hypotensive bleeding trauma patients 1
• Should be administered within 3 hours after injury in trauma patients with hemorrhagic shock 1
• Contraindicated in patients with severe traumatic brain injury due to its hypotonic nature, which may worsen cerebral edema 1, 2
• Preferred over 0.9% saline for large volume resuscitation to avoid hyperchloremic acidosis 1

Burn Management

• Recommended for fluid resuscitation in burn patients with:
  • ≥20% total body surface area (TBSA) burns in adults
  • ≥10% TBSA burns in children 3
• Administered as part of a balanced crystalloid approach for maintaining fluid balance in burn patients

Sepsis Management

• Associated with improved survival in sepsis-induced hypotension compared to 0.9% saline 4
• Provides more hospital-free days at 28 days compared to normal saline in septic patients 4
• Helps avoid hyperchloremic acidosis and decreased bicarbonate levels seen with large volumes of normal saline 4

Advantages Over Normal Saline

• Balanced electrolyte composition closer to plasma
• Less likely to cause hyperchloremic metabolic acidosis with large volume administration 1
• Contains lactate which can be metabolized to bicarbonate, helping maintain acid-base balance
• Associated with improved outcomes in sepsis 4

Contraindications and Cautions

1. Severe traumatic brain injury: Absolutely contraindicated due to hypotonic nature that may worsen cerebral edema 1, 2
2. Severe hyperkalemia: Contains 4 mEq/L of potassium
3. Severe metabolic alkalosis: Contains lactate which converts to bicarbonate
4. Severe liver dysfunction: May impair lactate metabolism

Dosing Considerations

• Trauma patients: Initial crystalloid bolus based on hemodynamic response and classification of shock 1

  • Class I shock: Crystalloid bolus of up to 750 mL
  • Class II shock: Crystalloid bolus of 750-1500 mL
  • Class III shock: Crystalloid bolus of 1500-2000 mL plus blood products
  • Class IV shock: Crystalloid bolus of >2000 mL plus immediate blood products

• Burn patients:

  • 20 mL/kg of balanced crystalloid solution in the first hour for adults with ≥20% TBSA burns
  • 20 mL/kg in the first hour for children with ≥10% TBSA burns 3

• Sepsis patients:

  • 1-3 L for initial fluid resuscitation 4

Common Misconceptions

1. Lactate elevation concerns: Administration of lactated Ringer's at resuscitation rates does not significantly increase serum lactate levels in a clinically meaningful way 5, 6

2. Peripheral edema: Both crystalloids and colloids can cause peripheral edema, but there is insufficient evidence regarding clinical significance or resolution time 1

Algorithm for Fluid Selection in Resuscitation

1. Assess for traumatic brain injury:

   • If present → Use 0.9% saline or other isotonic non-lactated solution
   • If absent → Proceed to next step

2. Evaluate clinical scenario:

   • Trauma with hemorrhagic shock → Lactated Ringer's (plus blood products as needed)
   • Burns meeting criteria → Lactated Ringer's
   • Sepsis with hypotension → Lactated Ringer's
   • Hyperkalemia → Consider 0.9% saline instead
   • Severe liver dysfunction → Consider 0.9% saline instead

3. Monitor response:

   • Vital signs
   • Urine output
   • Acid-base status
   • Electrolyte levels

By following this algorithm, clinicians can optimize fluid resuscitation while minimizing potential complications associated with inappropriate fluid selection.