Is it safe to mix multivitamins with Ringer's (Ringer lactate) lactate for infusion?

Mixing Multivitamins with Ringer's Lactate for Infusion

Multivitamins can be safely mixed with Ringer's lactate for infusion, but optimal stability is achieved when vitamins are added to lipid emulsions or lipid-containing mixtures rather than crystalloid solutions alone. 1

Key Compatibility Considerations

Vitamin Stability in Different Solutions

• Water and lipid-soluble vitamins should preferably be added to lipid emulsions or mixtures containing lipids to maximize vitamin stability and minimize degradation. 1

• When vitamins are mixed with glucose-amino acid solutions or crystalloid solutions like Ringer's lactate alone, significant losses can occur due to:

  • Light degradation (particularly vitamins A and E at wavelengths 330-350 nm and 285-305 nm respectively) 1
  • Adherence to tubing 1
  • Environmental factors including humidity and temperature 1

• The actual amount of vitamins delivered to the patient may be substantially lower than the intended dose, especially for vitamin A (retinol) and in situations with slow infusion rates. 1

Practical Administration Guidelines

• Vitamins should be administered daily when possible, with lipid-soluble vitamins given simultaneously with lipid emulsions. 1

• Vitamin K is an exception and can be given weekly rather than daily. 1

• Light protection measures should be implemented:

  • Red plastic bags are impervious to wavelengths 190-590 nm 1
  • Amber light-protecting tubing absorbs wavelengths 290-450 nm 1
  • Intense sunlight is the most detrimental factor for vitamin stability 1

Ringer's Lactate Compatibility Profile

General Drug Compatibility

• Ringer's lactate has been tested with 94 injectable drugs and found physically compatible with 86 of them during simulated Y-site administration for 4 hours. 2

• Eight drugs were incompatible with Ringer's lactate: ciprofloxacin, cyclosporine, diazepam, ketamine, lorazepam, nitroglycerin, phenytoin, and propofol. 2

Clinical Use Context

• Ringer's lactate is a standard crystalloid solution used routinely in perioperative and critical care settings. 1, 3

• The solution contains electrolytes and lactate, which does not falsely elevate circulating lactate concentrations when infused at resuscitation rates in hemodynamically stable patients. 4

Specific Populations

Pediatric Patients

• Preterm infants on parenteral nutrition should receive 10 μg/kg/day of vitamin K when vitamins are administered. 5

• Ringer's lactate with 0.9-1% dextrose is appropriate for routine perioperative infusion in pediatric patients. 3

• Adult multivitamin formulations containing propylene glycol and polysorbate additives are not recommended for infants due to potential toxicity concerns. 1

Monitoring Considerations

• Routine monitoring of vitamin concentrations (except vitamin D) is not recommended due to lack of evidence for adequate benefits. 1

• In patients on long-term parenteral nutrition (weeks), monitoring may be needed based on clinical indications. 1

Common Pitfalls to Avoid

• Do not assume full vitamin delivery when mixing with crystalloid solutions alone—actual delivered doses may be significantly lower than intended due to degradation and adherence losses. 1

• Avoid intermittent substitution (twice or three times weekly) as this carries a hypothetical risk of adverse effects from transient high vitamin levels. 1

• Do not expose vitamin-containing solutions to intense sunlight or prolonged light exposure without appropriate protection. 1

• Be aware that optimal parenteral vitamin requirements have never been definitively established, and current recommendations are based primarily on expert opinion rather than robust clinical trials. 1