Is Ringer lactate (lactated Ringer's solution) safe to use in patients with lactic acidosis?

Ringer Lactate in Lactic Acidosis

Ringer's lactate (lactated Ringer's solution) should be avoided in patients with lactic acidosis, as it may potentially worsen the acidotic state and is not recommended in this clinical scenario. 1

Rationale for Avoiding Lactated Ringer's in Lactic Acidosis

• Lactated Ringer's solution contains 28 mmol/L of sodium lactate, which can potentially contribute to increased serum lactate levels in patients who already have impaired lactate metabolism 2
• In patients with lactic acidosis, the body's ability to metabolize lactate is already compromised, and additional exogenous lactate from IV fluids may exacerbate the condition 3
• The European guideline on management of major bleeding and coagulopathy specifically recommends that saline solutions should not be used in severe acidosis, especially when associated with hyperchloremia, suggesting that alternative solutions should be considered 1

Preferred Fluid Options for Patients with Lactic Acidosis

• Balanced crystalloid solutions without lactate are preferred for fluid resuscitation in patients with lactic acidosis 1
• Normal saline (0.9% sodium chloride) should be used with caution and limited to a maximum of 1-1.5 L due to the risk of hyperchloremic acidosis, which can worsen metabolic acidosis 1
• Goal-directed fluid therapy should be implemented to optimize hemodynamics while avoiding fluid overload 1

Special Considerations

• In trauma patients with hemorrhagic shock who also have lactic acidosis, balanced electrolyte solutions without lactate are favored as the initial crystalloid solution 1
• For patients with severe head trauma, hypotonic solutions such as Ringer's lactate should be specifically avoided to prevent cerebral edema (Grade 1B recommendation) 1
• In septic patients with lactic acidosis, the Surviving Sepsis Campaign recommends balanced crystalloids instead of normal saline for resuscitation 1

Physiological Considerations

• Lactic acidosis in critically ill patients correlates with overall oxygen debt and survival; therefore, addressing the underlying cause of lactic acidosis is paramount 3
• The primary therapeutic goal should be to maximize oxygen delivery to tissues by optimizing cardiac output and maintaining adequate hemoglobin concentration 3
• While a study in healthy volunteers showed only a modest rise in serum lactate after LR administration, this may not translate to patients with impaired lactate metabolism 2

Monitoring Recommendations

• Regular monitoring of serum lactate levels, acid-base status, and electrolytes is essential when managing patients with lactic acidosis 4
• The trend of lactate levels over time is more informative than a single measurement and should guide ongoing fluid management 3
• Early identification and correction of acidotic states are crucial to prevent poor clinical outcomes, especially in ICU patients 4

In conclusion, while Ringer's lactate is generally a useful balanced crystalloid solution for many clinical scenarios, it should be avoided in patients with lactic acidosis due to the potential for worsening the underlying metabolic derangement. Alternative balanced crystalloid solutions without lactate are preferred in this specific patient population.