Does Lactated Ringer's (LR) solution cause hyperchloremia?

From the Guidelines

Lactated Ringer's (LR) solution does not cause high chloride levels, in fact, it contains less chloride (109 mEq/L) than normal saline (154 mEq/L), making it less likely to cause hyperchloremia. LR is a balanced crystalloid solution that more closely resembles the electrolyte composition of human plasma. When large volumes of fluid are needed, LR is often preferred over normal saline precisely because it reduces the risk of developing hyperchloremic metabolic acidosis, as supported by the study published in the World Journal of Emergency Surgery 1. The lactate in LR is metabolized to bicarbonate in the liver, which helps maintain acid-base balance. For patients with concerns about electrolyte imbalances, LR is generally a safer choice for volume resuscitation compared to normal saline, especially when larger volumes are required. However, LR should be used cautiously in patients with severe liver disease (who may not metabolize lactate effectively) and in those with severe hyperkalemia (as LR contains 4 mEq/L of potassium).

Some studies have suggested that balanced solutions like LR may have a favorable effect on renal function and survival compared to high-volume chloride-rich solutions, as seen in the SMART study 1. Additionally, the European guideline on management of major bleeding and coagulopathy following trauma recommends the use of balanced crystalloid solutions like LR in hypotensive bleeding trauma patients 1. However, it's essential to consider the specific context and patient population when making decisions about fluid therapy.

In terms of morbidity, mortality, and quality of life, the use of LR solution is associated with better outcomes compared to normal saline, particularly in patients who require large volumes of fluid resuscitation, as supported by the study published in Anaesthesia 1. Therefore, LR solution is a recommended choice for fluid resuscitation in patients with concerns about electrolyte imbalances or those who require large volumes of fluid.

Key points to consider when using LR solution include:

• LR contains less chloride than normal saline, making it less likely to cause hyperchloremia
• LR is a balanced crystalloid solution that closely resembles the electrolyte composition of human plasma
• LR reduces the risk of developing hyperchloremic metabolic acidosis
• LR should be used cautiously in patients with severe liver disease or severe hyperkalemia
• LR is associated with better outcomes compared to normal saline in patients who require large volumes of fluid resuscitation.

From the Research

Lactated Ringer's Solution and Chloride Levels

• The study 2 found that patients assigned to normal saline had progressively greater plasma chloride concentrations than those given lactated Ringer's across all volume categories.
• In contrast, the study 3 found that the NS group saw larger declines in pH and bicarbonate and greater increases in chloride compared with the LR group.
• The study 4 found that in the NS group, Cl- values increased significantly at the 2nd hour intraoperatively, whereas in the LR group, blood gas analysis and electrolyte values did not show any significant difference intraoperatively.
• The study 5 found that no difference was found in complications such as incidence of nongap metabolic acidosis, hyperchloremia between the LR and NS groups.

Key Findings

• Lactated Ringer's solution does not cause hyperchloremic metabolic acidosis as does normal saline during major surgery 4.
• Normal saline administration clearly causes volume-dependent hyperchloremia 2.
• There was no difference in mean serum lactate when comparing a 30 mL/kg bolus of NS to LR 3.
• Lactated Ringer's was associated with faster time to high anion gap metabolic acidosis resolution compared to NS 5.