Lactated Ringer's: Difference between revisions
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==Background== | ==Background== | ||
*Lactated Ringer's (LR) is a | *Lactated Ringer's (LR) is a balanced crystalloid solution with an electrolyte composition closer to human plasma than [[normal saline]] (0.9% NaCl) | ||
*Also known as Ringer's lactate or Hartmann's solution | *Also known as Ringer's lactate or Hartmann's solution | ||
| Line 26: | Line 26: | ||
*The 28 mEq/L of lactate is metabolized by the liver to bicarbonate, providing a buffering effect | *The 28 mEq/L of lactate is metabolized by the liver to bicarbonate, providing a buffering effect | ||
*LR is | *LR is slightly hypotonic (272 mOsm/L) compared to plasma | ||
==Advantages Over Normal Saline== | ==Advantages Over Normal Saline== | ||
| Line 32: | Line 32: | ||
*More physiologic electrolyte profile | *More physiologic electrolyte profile | ||
*'''SMART trial''' (2018): Balanced crystalloids reduced a composite of death, new renal-replacement therapy, or persistent renal dysfunction compared to NS in critically ill adults (14.3% vs 15.4%; OR 0.91)<ref name="SMART">Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):819-828.</ref> | *'''SMART trial''' (2018): Balanced crystalloids reduced a composite of death, new renal-replacement therapy, or persistent renal dysfunction compared to NS in critically ill adults (14.3% vs 15.4%; OR 0.91)<ref name="SMART">Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):819-828.</ref> | ||
* | *SMART sepsis subgroup: 30-day in-hospital mortality was lower with balanced crystalloids in patients with sepsis (25.2% vs 29.4%)<ref name="SMARTsepsis">Brown RM, Wang L, Coston TD, et al. Balanced Crystalloids versus Saline in Sepsis: A Secondary Analysis of the SMART Trial. Am J Respir Crit Care Med. 2019;200(12):1487-1495.</ref> | ||
* | *SALT-ED trial (2018): In non-critically ill ED patients admitted to the floor, balanced crystalloids reduced major adverse kidney events compared to NS (4.7% vs 5.6%)<ref name="SALTED">Self WH, Semler MW, Wanderer JP, et al. Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med. 2018;378(9):829-839.</ref> | ||
* | *SSC 2021 suggests balanced crystalloids over NS for sepsis resuscitation (weak recommendation)<ref name="SSC2021">Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021;49(11):e1063-e1143.</ref> | ||
* | *CLOVERS secondary analysis (2025): Initial resuscitation with LR vs NS in sepsis-induced hypotension was associated with lower 90-day mortality (12% vs 16%)<ref name="CLOVERS">Dahl RM, Dudaryk R, Casey JD, et al. Lactated Ringer's or Normal Saline for Initial Fluid Resuscitation in Sepsis-Induced Hypotension. Crit Care Med. 2025.</ref> | ||
===Limitations=== | ===Limitations=== | ||
| Line 44: | Line 44: | ||
;Myth: "LR is contraindicated in [[hyperkalemia]] because it contains potassium" | ;Myth: "LR is contraindicated in [[hyperkalemia]] because it contains potassium" | ||
* | *Reality: LR contains only 4 mEq/L K⁺, which is at or below normal serum K⁺. The hyperchloremic acidosis caused by NS can actually worsen hyperkalemia by driving K⁺ out of cells in exchange for H⁺. A SALT-ED subgroup analysis showed no increased incidence of severe hyperkalemia with balanced crystalloids<ref name="emDocs">emDOCs. Lactated Ringers versus Normal Saline: Myths and Pearls in the ED. 2021.</ref> | ||
*LR is | *LR is safe to use in patients with hyperkalemia | ||
;Myth: "LR cannot be co-infused with blood products because the calcium will cause clotting" | ;Myth: "LR cannot be co-infused with blood products because the calcium will cause clotting" | ||
* | *Reality: The amount of calcium in LR (3 mEq/L) is insufficient to overwhelm the citrate anticoagulant in modern blood products at standard infusion rates. Multiple studies have demonstrated no clinically significant clotting. The concern is largely historical. When in doubt, use a separate line or flush between products | ||
;Myth: "LR will falsely elevate the serum lactate" | ;Myth: "LR will falsely elevate the serum lactate" | ||
| Line 60: | Line 60: | ||
==Management== | ==Management== | ||
===Indications (Common ED Uses)=== | ===Indications (Common ED Uses)=== | ||
* | *[[Sepsis]] — SSC 2021 suggests balanced crystalloids as first-line fluid<ref name="SSC2021"/> | ||
* | *Volume resuscitation in [[hemorrhagic shock]], [[hypovolemia]], dehydration | ||
* | *[[DKA]] — LR is an appropriate alternative to NS; may cause less hyperchloremic acidosis during high-volume resuscitation | ||
* | *General maintenance fluids | ||
* | *Burn resuscitation (Parkland formula uses LR) | ||
* | *Intraoperative fluid replacement | ||
===Dosing=== | ===Dosing=== | ||
*Dosing is the same as NS — guided by clinical indication, not by fluid type | *Dosing is the same as NS — guided by clinical indication, not by fluid type | ||
* | *Sepsis/septic shock: SSC suggests 30 mL/kg within the first 3 hours for sepsis-induced hypoperfusion (weak recommendation); reassess after each bolus<ref name="SSC2021"/> | ||
* | *General resuscitation: 500-1000 mL bolus, reassess, repeat as clinically indicated | ||
* | *Maintenance: Weight-based (e.g. 4-2-1 rule) or clinical judgment | ||
===Situations Where NS May Be Preferred=== | ===Situations Where NS May Be Preferred=== | ||
* | *Severe isolated [[traumatic brain injury]] — some protocols prefer NS due to LR's slight hypotonicity (institutional variation) | ||
* | *[[Hyponatremia]] with risk of cerebral edema — NS or hypertonic saline preferred | ||
*'''Concurrent with [[ceftriaxone]]''' — LR contains calcium which can form precipitates with ceftriaxone; do not co-infuse through the same line (use a separate line or flush with NS between)<ref>Trissel LA. Handbook on Injectable Drugs. 17th ed. American Society of Health-System Pharmacists; 2013.</ref> | *'''Concurrent with [[ceftriaxone]]''' — LR contains calcium which can form precipitates with ceftriaxone; do not co-infuse through the same line (use a separate line or flush with NS between)<ref>Trissel LA. Handbook on Injectable Drugs. 17th ed. American Society of Health-System Pharmacists; 2013.</ref> | ||
* | *Metabolic alkalosis — NS provides chloride without the buffering effect of lactate → bicarbonate conversion | ||
==Disposition== | ==Disposition== | ||
| Line 88: | Line 88: | ||
*[[Hemorrhagic shock]] | *[[Hemorrhagic shock]] | ||
*[[DKA]] | *[[DKA]] | ||
*[[ | *[[Burns]] | ||
==External Links== | ==External Links== | ||
Latest revision as of 09:12, 22 March 2026
Background
- Lactated Ringer's (LR) is a balanced crystalloid solution with an electrolyte composition closer to human plasma than normal saline (0.9% NaCl)
- Also known as Ringer's lactate or Hartmann's solution
Composition
| Component | LR | Normal Saline | Human Plasma |
| Na⁺ (mEq/L) | 130 | 154 | 136-145 |
| Cl⁻ (mEq/L) | 109 | 154 | 98-106 |
| K⁺ (mEq/L) | 4 | 0 | 3.5-5.0 |
| Ca²⁺ (mEq/L) | 3 | 0 | 4.4-5.2 |
| Lactate (mEq/L) | 28 | 0 | 0.5-2.2 |
| Osmolarity (mOsm/L) | 272 | 308 | 275-295 |
| pH | 6.5 | 5.5 | 7.35-7.45 |
- The 28 mEq/L of lactate is metabolized by the liver to bicarbonate, providing a buffering effect
- LR is slightly hypotonic (272 mOsm/L) compared to plasma
Advantages Over Normal Saline
- Lower chloride content → less risk of hyperchloremic metabolic acidosis
- More physiologic electrolyte profile
- SMART trial (2018): Balanced crystalloids reduced a composite of death, new renal-replacement therapy, or persistent renal dysfunction compared to NS in critically ill adults (14.3% vs 15.4%; OR 0.91)[1]
- SMART sepsis subgroup: 30-day in-hospital mortality was lower with balanced crystalloids in patients with sepsis (25.2% vs 29.4%)[2]
- SALT-ED trial (2018): In non-critically ill ED patients admitted to the floor, balanced crystalloids reduced major adverse kidney events compared to NS (4.7% vs 5.6%)[3]
- SSC 2021 suggests balanced crystalloids over NS for sepsis resuscitation (weak recommendation)[4]
- CLOVERS secondary analysis (2025): Initial resuscitation with LR vs NS in sepsis-induced hypotension was associated with lower 90-day mortality (12% vs 16%)[5]
Limitations
- A large Canadian crossover trial (BaSICS-like design, NEJM 2024) of hospital-wide LR vs NS policy found no significant difference in death or readmission at 90 days among all hospitalized patients, suggesting the benefit may be most relevant in critically ill and sepsis populations[6]
Common ED Myths vs. Reality
- Myth
- "LR is contraindicated in hyperkalemia because it contains potassium"
- Reality: LR contains only 4 mEq/L K⁺, which is at or below normal serum K⁺. The hyperchloremic acidosis caused by NS can actually worsen hyperkalemia by driving K⁺ out of cells in exchange for H⁺. A SALT-ED subgroup analysis showed no increased incidence of severe hyperkalemia with balanced crystalloids[7]
- LR is safe to use in patients with hyperkalemia
- Myth
- "LR cannot be co-infused with blood products because the calcium will cause clotting"
- Reality: The amount of calcium in LR (3 mEq/L) is insufficient to overwhelm the citrate anticoagulant in modern blood products at standard infusion rates. Multiple studies have demonstrated no clinically significant clotting. The concern is largely historical. When in doubt, use a separate line or flush between products
- Myth
- "LR will falsely elevate the serum lactate"
- Reality: LR does not meaningfully raise serum lactate levels. The lactate in LR is rapidly metabolized to bicarbonate by the liver. Only in the setting of massive resuscitation (many liters) with severe hepatic failure might this become a theoretical concern. Standard resuscitation volumes do not affect lactate interpretation[7]
- Caution
- Traumatic brain injury (TBI)
- LR is slightly hypotonic (272 mOsm/L); large volumes may theoretically worsen cerebral edema in severe TBI
- Some guidelines and protocols prefer NS or hypertonic saline for TBI resuscitation; however, clinical evidence of harm from LR specifically in TBI is limited
- Reasonable to use NS for primary resuscitation in severe isolated TBI if your institution's protocol specifies it
Management
Indications (Common ED Uses)
- Sepsis — SSC 2021 suggests balanced crystalloids as first-line fluid[4]
- Volume resuscitation in hemorrhagic shock, hypovolemia, dehydration
- DKA — LR is an appropriate alternative to NS; may cause less hyperchloremic acidosis during high-volume resuscitation
- General maintenance fluids
- Burn resuscitation (Parkland formula uses LR)
- Intraoperative fluid replacement
Dosing
- Dosing is the same as NS — guided by clinical indication, not by fluid type
- Sepsis/septic shock: SSC suggests 30 mL/kg within the first 3 hours for sepsis-induced hypoperfusion (weak recommendation); reassess after each bolus[4]
- General resuscitation: 500-1000 mL bolus, reassess, repeat as clinically indicated
- Maintenance: Weight-based (e.g. 4-2-1 rule) or clinical judgment
Situations Where NS May Be Preferred
- Severe isolated traumatic brain injury — some protocols prefer NS due to LR's slight hypotonicity (institutional variation)
- Hyponatremia with risk of cerebral edema — NS or hypertonic saline preferred
- Concurrent with ceftriaxone — LR contains calcium which can form precipitates with ceftriaxone; do not co-infuse through the same line (use a separate line or flush with NS between)[8]
- Metabolic alkalosis — NS provides chloride without the buffering effect of lactate → bicarbonate conversion
Disposition
Not applicable — this is a medication/fluid page. Disposition is determined by the underlying condition being treated.
See Also
External Links
- emDOCs - Lactated Ringers vs Normal Saline: Myths and Pearls in the ED
- The Bottom Line - SMART Trial Summary
- NEJM - SMART Trial (Full Text)
- NEJM - SALT-ED Trial (Full Text)
References
- ↑ Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):819-828.
- ↑ Brown RM, Wang L, Coston TD, et al. Balanced Crystalloids versus Saline in Sepsis: A Secondary Analysis of the SMART Trial. Am J Respir Crit Care Med. 2019;200(12):1487-1495.
- ↑ Self WH, Semler MW, Wanderer JP, et al. Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med. 2018;378(9):829-839.
- ↑ 4.0 4.1 4.2 Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021;49(11):e1063-e1143.
- ↑ Dahl RM, Dudaryk R, Casey JD, et al. Lactated Ringer's or Normal Saline for Initial Fluid Resuscitation in Sepsis-Induced Hypotension. Crit Care Med. 2025.
- ↑ Bhatt DL, Bhatt M, et al. A Crossover Trial of Hospital-Wide Lactated Ringer's Solution versus Normal Saline. N Engl J Med. 2024.
- ↑ 7.0 7.1 emDOCs. Lactated Ringers versus Normal Saline: Myths and Pearls in the ED. 2021.
- ↑ Trissel LA. Handbook on Injectable Drugs. 17th ed. American Society of Health-System Pharmacists; 2013.