differences & indications of ringers (solution/buffered with lactate & acetate) Vs Normal saline in different medical conditions Presented as lecture at 25th.July 2022

1. Alaa Fadhel Hassan
(MSc. Pharmacology)
Drug Information &/pharmacovigilance Centre

2.  0.9% Sodium chloride.
 Common solution for preoperative management, dissolving drugs for
intravenous infusions, correcting metabolic alkalosis (particularly
hypochloremic alkalosis associated with vomiting).
 However, it is associated with hyperchloraemic metabolic acidosis due
to the supra-physiological concentrations of sodium (154mmol/L) and
chloride (154mmol/L), raising blood potassium level in excessive &
large amount infusions (also known to dilate blood vessels).

4.  These are sterile solutions composed of sodium chloride, potassium
chloride & calcium chloride ± sodium (lactate/ acetate/ gluconate
&/malate).
 Worldwide they are named lactated or acetated Ringer’s solutions
(after British physiologist), or Hartmann’s solution (after U.S.
pediatrician who in the 1930s added lactate as a buffer).
 These are common IV fluids for hypotension /hypovolemia &
dehydration (restore body fluid in pt. with severe blood loss & burns),
keep opened IV catheters, resuscitation and for perioperative
maintenance & also dissolving drugs for intravenous infusions.

5.  The extracellular deficit after fasting is low.
 The basal fluid loss via insensible mechanisms is also low and
approximately 0.5 mL/kg/hr, extending to 1 mL/kg/hr during more
extensive surgery.
 Evidence for a fluid consuming third space is not compelling.
 Fluids are context-sensitive (there is momentarily a limited space in
the plasma volume before a fluid load is eliminated), meaning that
they should be infused and titrated according to needs and not too
rapidly.

6.  Ringers solutions are slightly hypotonic (the buffered solutions mainly,
due to he lower sodium concentration than extracellular fluid) with
lower caloric, but associated with few side effects. All of them are
slightly vasodilatory and inflammatory.
 They distribute from the plasma to the interstitium in approximately
25 to 30 minutes with a distribution half-time of approximately 8
minutes.
 Associated with oedema (excessive use), injection site pain, allergic
reactions (rare), problematic for pt. with CHF, CKD, cirrhosis,
hypoalbuminemia & severe hepatic disorders.

7.  Ringer lactate (LR: sodium lactate
buffered sol.), metabolized to
bicarbonate in the hepatic & renal tissue,
thus their safety for pt. with reduced
lactate metabolism attributable to acute
or chronic hepatic failure is questionable.
 Also they have higher potential to
increase plasma lactate and induce
hyperglycaemia (lactate is a metabolically
active compound during
gluconeogenesis), thus excessive use
could be a concern in the treatment of
diabetic patients.

8.  Ringer acetate (AR: sodium acetate buffered sol.), metabolized to
bicarbonate in several organs, mainly in peripheral skeletal muscles.
 Ringer acetate is metabolized faster than lactated solutions,
furthermore; lactated ringer requires more oxygen for metabolism
lead to a slight increase in plasma glucose.
 It’s been suggested that acetate may affect myocardial contractility
and aggravate hemodynamic instability (that’s why it is discontinued
from haemodialysis units).
 Ringer acetate is preferred for pt. with hepatic disorders.

9.  Ceftriaxone (avoid with pt. < 28 days, otherwise; for older pt. use separate
line for infusion) & Ciprofloxacin.
 Mannitol.
 Methyl prednisolone.
 Nitroglycerin/Nitroprusside, Norepinephrine, Procainamide & Propranolol.
 Cyclosporine.
 Diazepam, Ketamine, Lorazepam & Propofol.
 Phenytoin.
 Preserved blood with citrate anticoagulant (theoretical risk of coagulation,
use a separate line/ alternative IV fluid).

10.  Pearl: Two RCTs show that both non-critically ill and critically ill
patients who received balanced crystalloids were less likely to have
renal injury leading to need for renal replacement therapy or to have
persistent renal dysfunction, but an additional large ICU based RCT did
not show statistical difference in balanced crystalloid versus NS.
 Pearl: Sodium lactate, generally metabolized by the body and does not
contribute to worsening lactic acidosis. In fact, the acidosis associated
with NS likely has more clinically harmful effects. [Lactate addition
reduce acidity as it converted to bicarbonate (regulate body PH
balance & avoid acidosis & metabolized under ischemic conditions
and decrease overall cell death). So dose not remain in the body as
long as saline, less likely to cause complication as hypervolemia].

11.  Concerning as a potential risk factor for acute kidney injury in
critically ill patients. Thus, based on their buffering capacity, lower
chloride content, and respective side-effect profiles, balanced
crystalloid solutions (LR) are deemed to be the superior resuscitative
fluid compared with NS by some authorities. Still, improvements in
outcome have not been consistently documented with both in acute
kidney injury. (Currently there is no consensus in selecting a balanced
crystalloid solution over NS).
 Pearl: Though theoretical risk of clotting exists, LR can be administered
simultaneously in patients >28 days with ceftriaxone, blood products
and other calcium-containing medications..

12.  Pearl: LR is a safe fluid to use in resuscitation of patients with elevated
potassium levels. The potassium/hydrogen shifts that occur as result of the
acidic environment from NS infusion may worsen serum potassium levels.
 Pearl: Several studies showed that balanced crystalloids are associated with
improved outcomes in patients with DKA, dehydration, and pancreatitis.
 In acute normovolaemic haemodilution experiments in human
subjects as a model for acute blood loss, 17% of infused LR remained
intravascular. Plasma volume was subsequently restored and
interstitial oedema that developed after LR infusion (reduced by
infusing albumin 20%).

13.  Pearl: In patients presenting with hyponatremia and acute burns, LR is not
necessarily the sole fluid choice for resuscitation, and NS is preferred in
patients with concern for (TBI) traumatic brain injury.
 In acute burns, there is concern for both dehydration and electrolyte
imbalances ex: hyponatremia and hypoglycemia secondary to evaporative
losses and changes in cellular permeability (LR contains 130 mEq/L Na
compared to 135-145mEq/L Na in plasma. Because of this, there is concern
that resuscitation with LR may worsen or lead to hyponatremia), Still burn
pt. Treated with LR showed statistically significant less evidence of
hyponatremia and hypoglycemia.
 Due to the hyperosmolarity of the solution and ability to decrease
cerebral oedema, NS is the preferred resuscitation fluid in patients with
TBI when compared with LR since the latter is thought to increase
neutrophil and inflammatory responses.

14.  Jennifer Whitlock. Lactated Ringer’s Solution vs. Normal Saline. Verywellhealth website.
24th May 2022.
 Bradley A. Boucher and G. Christopher Wood. Cahpter 13: Hypovolumic shock.
Pharmacotherapy principles and practice. MacGraw Hill Education 5th Ed. 2019
 Gabrielle Leonard. Lactated Ringers versus Normal Saline: Myths and Pearls in the ED.
emDocs.net. 30 Aug. 2021.
 Ellekjaer, Karen L. et al. Lactate versus acetate buffered intravenous crystalloid solutions: a
scoping review. British Journal of Anaesthesia, Volume 125, Issue 5, 693 – 703.
 Christer Svensén, Peter Rodhe. Chapter 33 - Intravascular Volume Replacement Therapy,
Editor(s): Hugh C. Hemmings, Talmage D. Egan. Pharmacology and Physiology for
Anesthesia, W.B. Saunders, 2013. Pages 574-592. ISBN 9781437716795.
 C. Boer, S. M. Bossers and N. J. Koning. Choice of fluid type: physiological concepts and
perioperative indications. British Journal of Anaesthesia, 120 (2): 384e396 (2018).
 Eric Walter. IV Crystalloids: Is One Better Than the Other? Relias Media website. February
1, 2016.