In sepsis with elevated lactic acid, should I use Lactated Ringer's (LR) or Normal Saline for fluid resuscitation?

Fluid Resuscitation in Sepsis with Elevated Lactic Acid

For sepsis patients with elevated lactic acid, either balanced crystalloids (Lactated Ringer's) or normal saline can be used for fluid resuscitation, with a slight preference for balanced crystalloids due to lower risk of hyperchloremic acidosis. 1

Initial Fluid Resuscitation Approach

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion (strong recommendation, low quality of evidence) 1
• Continue fluid administration using a fluid challenge technique as long as hemodynamic factors continue to improve 1
• Target a mean arterial pressure of 65 mmHg in patients requiring vasopressors 1
• Guide resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion 1, 2

Choice of Crystalloid Solution

• Both balanced crystalloids (like Lactated Ringer's) and normal saline are acceptable options for fluid resuscitation in sepsis and septic shock (weak recommendation, low quality of evidence) 1

• Normal saline has been associated with:

  • Higher risk of hyperchloremic acidosis 3, 4
  • Potentially greater fluid volume requirements 5, 4
  • Higher incidence of hyperlactacidemia in some studies 4

• Lactated Ringer's (LR) considerations:

  • Contains 28 mmol/L of sodium lactate but does not significantly raise serum lactate compared to normal saline in healthy individuals 3
  • May be associated with lower blood transfusion requirements and total fluid volume needs 4
  • Provides more physiologic electrolyte composition 5, 6

Common Misconceptions About LR in Elevated Lactate States

• Despite theoretical concerns, administration of LR does not significantly worsen lactate levels compared to normal saline 3
• The lactate in LR is metabolized by the liver and does not contribute significantly to lactic acidosis 3
• The benefit of balanced pH and electrolyte composition of LR may outweigh theoretical concerns about its lactate content 5, 4

Monitoring During Fluid Resuscitation

• Perform frequent reassessment of hemodynamic status including:
  • Clinical examination (heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output) 1
  • Lactate levels to guide resuscitation and assess response to therapy 2
  • Consider dynamic over static variables to predict fluid responsiveness when available 1

Additional Fluid Considerations

• Consider albumin in addition to crystalloids when patients require substantial amounts of crystalloids (weak recommendation, low quality of evidence) 1
• Avoid hydroxyethyl starches for intravascular volume replacement (strong recommendation, high quality of evidence) 1
• Use crystalloids over gelatins when resuscitating patients (weak recommendation, low quality of evidence) 1

Key Pitfalls to Avoid

• Don't delay fluid resuscitation while waiting for specific laboratory results 1, 2
• Don't withhold LR due to concerns about worsening lactate levels, as this effect is minimal 3
• Don't focus solely on fluid administration without reassessing response and considering vasopressors when appropriate 1
• Avoid excessive fluid administration, which can lead to pulmonary edema and other complications 7