Ringer Acetate vs Ringer Lactate in Critically Ill Patients with Sepsis
Either Ringer's acetate or Ringer's lactate can be used for resuscitation in critically ill septic patients, as both are balanced crystalloids and current guidelines make no distinction between them. 1, 2
Guideline Recommendations
The most recent Surviving Sepsis Campaign guidelines (2016) recommend crystalloids as the fluid of choice for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock (strong recommendation, moderate quality evidence). 1
Critically, the guidelines suggest using either balanced crystalloids or saline for fluid resuscitation, with only a weak recommendation and low quality of evidence. 1 This means the choice between Ringer's acetate and Ringer's lactate is left to clinical judgment, as both are considered balanced crystalloids.
Evidence Supporting Balanced Crystalloids
Balanced crystalloids (including both Ringer's acetate and Ringer's lactate) should be preferred over normal saline to reduce the risk of hyperchloremic metabolic acidosis. 2
The 6S Trial specifically showed that Ringer's acetate had lower mortality compared to hydroxyethyl starch in septic patients (43% vs 51%, P = 0.03), supporting the use of balanced solutions. 1, 2
Lactated Ringer's has been shown to reduce mortality more than saline in sepsis patients (adjusted hazard ratio 0.59; 95% CI 0.43-0.81) and provide shorter hospital stays. 3
Practical Algorithm for Fluid Selection
Initial resuscitation approach:
Administer at least 30 mL/kg of crystalloid within the first 3 hours of sepsis recognition. 1, 2, 4
Choose either Ringer's acetate or Ringer's lactate as your balanced crystalloid. 1
Continue fluid administration as long as hemodynamic parameters improve using dynamic measures (pulse pressure variation, stroke volume variation) or static variables (arterial pressure, heart rate). 1, 2
Specific Considerations for Choosing Between the Two
Ringer's lactate may be preferred in:
- Patients with chronic pulmonary disease, where it provides greater mortality benefit. 3
- Patients without significant liver disease. 3
Ringer's acetate may be preferred in:
- Patients with moderate to severe liver disease, as lactate metabolism requires hepatic function and serum lactate levels rise significantly higher with Ringer's lactate in liver disease patients. 3
- Patients with chronic kidney disease, where the benefits of Ringer's lactate are smaller and non-significant. 3
Common Pitfalls to Avoid
Do not use normal saline as your primary resuscitation fluid when balanced crystalloids are available, as it increases the risk of hyperchloremic metabolic acidosis and potentially acute kidney injury. 2, 5
Do not delay resuscitation due to concerns about which specific balanced crystalloid to use – both are acceptable and far superior to normal saline. 1, 2
In patients with liver disease receiving Ringer's lactate, do not misinterpret rising lactate levels as worsening tissue hypoperfusion, as this may reflect impaired hepatic lactate metabolism rather than inadequate resuscitation. 3
Do not use hydroxyethyl starches for fluid resuscitation, as they are strongly contraindicated and increase mortality. 1, 2