Ringer's lactate solution

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Ringer's lactate solution
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A bottle of Ringer's lactate solution
Clinical data
Other namescompound sodium lactate, sodium lactate solution, Hartmann's solution, Ringer-Locke's solution, Ringer-lactate, lactated Ringer's solution (LRS)
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administration 		intravenous, topical, subcutaneous
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Ringer's lactate solution (RL), also known as sodium lactate solution,Lactated Ringer's (LR), and Hartmann's solution, is a mixture of sodium chloride, sodium lactate, potassium chloride, and calcium chloride in water. [1] It is used for replacing fluids and electrolytes in those who have low blood volume or low blood pressure. [2] It may also be used to treat metabolic acidosis and to wash the eye following a chemical burn. [2] [3] It is given by intravenous infusion or applied to the affected area. [2] [3]

Contents

Side effects may include allergic reactions, high blood potassium, hypervolemia, and high blood calcium. [2] It may not be suitable for mixing with certain medications and some recommend against use in the same infusion as a blood transfusion. [4] Ringer's lactate solution has a lower rate of acidosis as compared with normal saline. [1] [4] Use is generally safe in pregnancy and breastfeeding. [2] Ringer's lactate solution is in the crystalloid family of medications. [5] It is isotonic, i.e. it has the same tonicity as blood. [2]

Ringer's solution was invented in the 1880s; lactate was added in the 1930s. [4] It is on the World Health Organization's List of Essential Medicines. [6] Lactated Ringer's is available as a generic medication. [1] For people with liver dysfunction, Ringer's acetate may be a better alternative with the lactate replaced by acetate. [7] In Scandinavia Ringer's acetate is typically used. [8]

Medical uses

Ringer's lactate solution is commonly used for fluid resuscitation after blood loss due to trauma, or surgery. [9] [10]

It is extensively used in aggressive volume resuscitation, e.g. for patients with pancreatitis, hemorrhagic shock or major burn injuries. [10] Since the lactate is converted into bicarbonate, caution should be used as patients may become alkalotic. [11] In acidotic states, such as in acute kidney failure, Ringer's lactate solution may be advantageous as the byproducts of lactate metabolism in the liver counteract the acidosis. [12] In a large-volume resuscitation over several hours, Ringer's lactate solution maintains a more stable blood pH than normal saline. [4]

Ringer's lactate and other crystalloid fluids are also used as vehicles for the intravenous (IV) delivery of medications. [10]

Chemistry

One liter of Ringer's lactate solution contains: [13]

Ringer's lactate has an osmolarity of 273 mOsm L−1 [14] and a pH of 6.5. [10] The lactate is metabolized into bicarbonate by the liver, which can help correct metabolic acidosis. Ringer's lactate solution alkalinizes via its consumption in the citric acid cycle, the generation of a molecule of carbon dioxide which is then excreted by the lungs. They increase the strong ion difference in solution, leading to proton consumption and an overall alkalinizing effect. [15]

The solution is formulated to have concentrations of potassium and calcium that are similar to the ionized concentrations found in normal blood plasma. To maintain electrical neutrality, the solution has a lower level of sodium than that found in blood plasma or normal saline. [4]

Generally, the source of the constituent ions is a mixture of sodium chloride (NaCl), sodium lactate (CH3CH(OH)CO2Na), calcium chloride (CaCl2), and potassium chloride (KCl), dissolved into distilled water. Ringer's solution has the same constituents without the sodium lactate, though sometimes it may also include magnesium chloride (MgCl2). [16] [17]

There are slight variations for the composition for Ringer's as supplied by different manufacturers. As such, the term Ringer's lactate should not be equated with one precise formulation. [18]

History

Ringer's saline solution was invented in the early 1880s by Sydney Ringer, [4] a British physician and physiologist. Ringer was studying the beating of an isolated frog heart outside of the body. He hoped to identify the substances in blood that would allow the isolated heart to beat normally for a time. [19] The use of Ringer's original solution of inorganic salts slowly became more popular. [4] In the 1930s, the original solution was further modified by American pediatrician Alexis Hartmann for the purpose of treating acidosis. Hartmann added lactate, which mitigates changes in pH by acting as a buffer for acid. Thus the solution became known as "Ringer's lactate solution" or "Hartmann's solution". [4] [20]

Formulations

Ringer's solution technically refers only to the saline component, without lactate. Some countries instead use a Ringer's acetate solution or Ringer-acetate, which has similar properties. This was thought to be helpful when analyzing blood-lactate for signs of anaerobic metabolism (e.g. present with septic shock, hypovolemic shock). Subsequently, it has been shown that lactate is metabolized much faster than infused. [21] Ringers lactate should not cause an elevated blood-lactate level except possibly in the most severe presentations of liver failure.[ citation needed ]

Veterinary use

It is used for the treatment or palliative care of chronic kidney failure in small animals. The solution can be administered intravenously or subcutaneously. Administering the fluids subcutaneously allows the solution to be readily given to the animal by a trained layperson, as it is not required that a vein be located. The solution is slowly absorbed from beneath the skin into the bloodstream of the animal. [22]

See also

Related Research Articles

<span class="mw-page-title-main">Diabetic ketoacidosis</span> Medical condition

Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus. Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion and occasionally loss of consciousness. A person's breath may develop a specific "fruity" smell. The onset of symptoms is usually rapid. People without a previous diagnosis of diabetes may develop DKA as the first obvious symptom.

<span class="mw-page-title-main">Intravenous therapy</span> Medication administered into a vein

Intravenous therapy is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutrients for those who cannot, or will not—due to reduced mental states or otherwise—consume food or water by mouth. It may also be used to administer medications or other medical therapy such as blood products or electrolytes to correct electrolyte imbalances. Attempts at providing intravenous therapy have been recorded as early as the 1400s, but the practice did not become widespread until the 1900s after the development of techniques for safe, effective use.

<span class="mw-page-title-main">Lactic acidosis</span> Metabolic medical condition

Lactic Acidosis refers to the process leading to the production of lactate by anaerobic metabolism. It increases hydrogen ion concentration tending to the state of acidemia or low pH. The result can be detected with high levels of lactate and low levels of bicarbonate. This is usually considered the result of illness but also results from strenuous exercise. The effect on pH is moderated by the presence of respiratory compensation.

<span class="mw-page-title-main">Fluid replacement</span> Medical practice of replenishing bodily fluid

Fluid replacement or fluid resuscitation is the medical practice of replenishing bodily fluid lost through sweating, bleeding, fluid shifts or other pathologic processes. Fluids can be replaced with oral rehydration therapy (drinking), intravenous therapy, rectally such as with a Murphy drip, or by hypodermoclysis, the direct injection of fluid into the subcutaneous tissue. Fluids administered by the oral and hypodermic routes are absorbed more slowly than those given intravenously.

<span class="mw-page-title-main">Hyperkalemia</span> Excess potassium in the blood

Hyperkalemia is an elevated level of potassium (K+) in the blood. Normal potassium levels are between 3.5 and 5.0 mmol/L (3.5 and 5.0 mEq/L) with levels above 5.5 mmol/L defined as hyperkalemia. Typically hyperkalemia does not cause symptoms. Occasionally when severe it can cause palpitations, muscle pain, muscle weakness, or numbness. Hyperkalemia can cause an abnormal heart rhythm which can result in cardiac arrest and death.

<span class="mw-page-title-main">Electrolyte imbalance</span> Abnormality in the concentration of electrolytes in the body

Electrolyte imbalance, or water-electrolyte imbalance, is an abnormality in the concentration of electrolytes in the body. Electrolytes play a vital role in maintaining homeostasis in the body. They help to regulate heart and neurological function, fluid balance, oxygen delivery, acid–base balance and much more. Electrolyte imbalances can develop by consuming too little or too much electrolyte as well as excreting too little or too much electrolyte. Examples of electrolytes include calcium, chloride, magnesium, phosphate, potassium, and sodium.

<span class="mw-page-title-main">Hypokalemia</span> Insufficient potassium in the blood

Hypokalemia is a low level of potassium (K+) in the blood serum. Mild low potassium does not typically cause symptoms. Symptoms may include feeling tired, leg cramps, weakness, and constipation. Low potassium also increases the risk of an abnormal heart rhythm, which is often too slow and can cause cardiac arrest.

Hypernatremia, also spelled hypernatraemia, is a high concentration of sodium in the blood. Early symptoms may include a strong feeling of thirst, weakness, nausea, and loss of appetite. Severe symptoms include confusion, muscle twitching, and bleeding in or around the brain. Normal serum sodium levels are 135–145 mmol/L. Hypernatremia is generally defined as a serum sodium level of more than 145 mmol/L. Severe symptoms typically only occur when levels are above 160 mmol/L.

Hypermagnesemia is an electrolyte disorder in which there is a high level of magnesium in the blood. Symptoms include weakness, confusion, decreased breathing rate, and decreased reflexes. Hypermagnesemia can greatly increase the chances of adverse cardiovascular events. Complications may include low blood pressure and cardiac arrest.

Hyperchloremia is an electrolyte disturbance in which there is an elevated level of chloride ions in the blood. The normal serum range for chloride is 96 to 106 mEq/L, therefore chloride levels at or above 110 mEq/L usually indicate kidney dysfunction as it is a regulator of chloride concentration. As of now there are no specific symptoms of hyperchloremia; however, it can be influenced by multiple abnormalities that cause a loss of electrolyte-free fluid, loss of hypotonic fluid, or increased administration of sodium chloride. These abnormalities are caused by diarrhea, vomiting, increased sodium chloride intake, renal dysfunction, diuretic use, and diabetes. Hyperchloremia should not be mistaken for hyperchloremic metabolic acidosis as hyperchloremic metabolic acidosis is characterized by two major changes: a decrease in blood pH and bicarbonate levels, as well as an increase in blood chloride levels. Instead those with hyperchloremic metabolic acidosis are usually predisposed to hyperchloremia.

<span class="mw-page-title-main">Saline (medicine)</span> Saline water for medical purposes

Saline is a mixture of sodium chloride (salt) and water. It has a number of uses in medicine including cleaning wounds, removal and storage of contact lenses, and help with dry eyes. By injection into a vein, it is used to treat dehydration such as that from gastroenteritis and diabetic ketoacidosis. Large amounts may result in fluid overload, swelling, acidosis, and high blood sodium. In those with long-standing low blood sodium, excessive use may result in osmotic demyelination syndrome.

The anion gap is a value calculated from the results of multiple individual medical lab tests. It may be reported with the results of an electrolyte panel, which is often performed as part of a comprehensive metabolic panel.

<span class="mw-page-title-main">Metabolic alkalosis</span> Abnormally high tissue pH due to metabolic dysfunction

Metabolic alkalosis is an acid-base disorder in which the pH of tissue is elevated beyond the normal range (7.35–7.45). This is the result of decreased hydrogen ion concentration, leading to increased bicarbonate, or alternatively a direct result of increased bicarbonate concentrations. The condition typically cannot last long if the kidneys are functioning properly.

<span class="mw-page-title-main">Calcium gluconate</span> Chemical compound

Calcium gluconate is the calcium salt of gluconic acid and is used as a mineral supplement and medication. As a medication it is used by injection into a vein to treat low blood calcium, high blood potassium, and magnesium toxicity. Supplementation is generally only required when there is not enough calcium in the diet. Supplementation may be done to treat or prevent osteoporosis or rickets. It can also be taken by mouth but is not recommended for injection into a muscle.

A volume expander is a type of intravenous therapy that has the function of providing volume for the circulatory system. It may be used for fluid replacement or during surgery to prevent nausea and vomiting after surgery.

<span class="mw-page-title-main">Ringer's solution</span> Electrolyte solution for use in healthcare

Ringer's solution is a solution of several salts dissolved in water for the purpose of creating an isotonic solution relative to the body fluids of an animal. Ringer's solution typically contains sodium chloride, potassium chloride, calcium chloride and sodium bicarbonate, with the last used to balance the pH. Other additions can include chemical fuel sources for cells, including ATP and dextrose, as well as antibiotics and antifungals.

A balanced salt solution (BSS) is a solution made to a physiological pH and isotonic salt concentration. Solutions most commonly include sodium, potassium, calcium, magnesium, and chloride. Balanced salt solutions are used for washing tissues and cells and are usually combined with other agents to treat the tissues and cells. They provide the cells with water and inorganic ions, while maintaining a physiological pH and osmotic pressure.

The Hs and Ts is a mnemonic used to aid in remembering the possible reversible causes of cardiac arrest. A variety of disease processes can lead to a cardiac arrest; however, they usually boil down to one or more of the "Hs and Ts".

<span class="mw-page-title-main">Intravenous sodium bicarbonate</span> Pharmaceutical drug

Intravenous sodium bicarbonate, also known as sodium hydrogen carbonate, is a medication primarily used to treat severe metabolic acidosis. For this purpose it is generally only used when the pH is less than 7.1 and when the underlying cause is either diarrhea, vomiting, or the kidneys. Other uses include high blood potassium, tricyclic antidepressant overdose, and cocaine toxicity as well as a number of other poisonings. It is given by injection into a vein.

Alexis Frank Hartmann Sr. was an American pediatrician and clinical biochemist. He is best known for adding sodium lactate to Ringer's solution, creating what is now known as Ringer's lactate solution or Hartmann's solution for intravenous infusions.

References

  1. 1 2 3 British national formulary: BNF 69 (69 ed.). British Medical Association. 2015. p. 683. ISBN   9780857111562.
  2. 1 2 3 4 5 6 "Compound Sodium Lactate Solution for Infusion - Summary of Product Characteristics (SPC) - (eMC)". www.medicines.org.uk. February 2013. Archived from the original on 16 January 2017. Retrieved 14 January 2017.
  3. 1 2 Krieglstein GK (2000). Atlas of Ophthalmology. Springer Science & Business Media. p. 377. ISBN   9783540780694. Archived from the original on 16 January 2017.
  4. 1 2 3 4 5 6 7 8 Marino PL, Sutin KM (2012). The ICU Book (3rd ed.). Lippincott Williams & Wilkins. p. 363. ISBN   9781451161557. Archived from the original on 18 September 2017.
  5. ↑ Saade GR, Foley MR, Phelan III JP, Dildy GA (2010). Critical Care Obstetrics. John Wiley & Sons. p. 70. ISBN   9781444396140. Archived from the original on 16 January 2017.
  6. ↑ World Health Organization (2019). World Health Organization model list of essential medicines: 21st list 2019. Geneva: World Health Organization. hdl: 10665/325771 . WHO/MVP/EMP/IAU/2019.06. License: CC BY-NC-SA 3.0 IGO.
  7. ↑ Marino PL (2013). Marino's The ICU Book (4 ed.). Lippincott Williams & Wilkins. p. 223. ISBN   9781469831640. Archived from the original on 16 January 2017.
  8. ↑ Bjarby J. "Vätsketerapi för AT/ST läkare KSS — 'Rehydration therapy for interns and specialists, KSS'" (PDF). Västragötalandsregionen. Archived (PDF) from the original on 16 January 2017. Retrieved 13 January 2017.
  9. ↑ Pestana C (7 April 2020). Pestana's Surgery Notes (Fifth ed.). Kaplan Medical Test Prep. pp. 4–5. ISBN   978-1506254340. The treatment of hemorrhagic shock in the urban setting (big trauma center nearby)...starts with the surgical intervention to stop the bleeding, and volume replacement takes place afterward. In all other settings, volume replacement is the first step, starting with about 2 L of Ringer's lactate (without sugar), and followed by blood (packed red cells)
  10. 1 2 3 4 Singh S, Kerndt CC, Davis D (2021). "Ringer's Lactate". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   29763209 . Retrieved 14 July 2021. Ringer's lactate is largely used in aggressive volume resuscitation from blood loss or burn injuries
  11. ↑ B. Braun Medical Inc. "Human Prescription Drug Label: Lactated Ringers (sodium chloride, sodium lactate, potassium chloride, and calcium chloride) injection, solution". DailyMed . U.S. National Library of Medicine. Archived from the original on 26 August 2014. ADVERSE REACTIONS [...] although the metabolism of lactate to bicarbonate is a relatively slow process, aggressive administration of sodium lactate may result in metabolic alkalosis. Careful monitoring of blood acid-base balance is essential during the administration of sodium lactate.
  12. ↑ "Lactated Ringer's (sodium chloride, sodium lactate, potassium chloride and calcium chloride) Injection". DailyMed . U.S. National Library of Medicine. Archived from the original on 6 March 2010.
  13. ↑ Ogbru D (21 October 2022). Davis CP (ed.). "Lactated Ringer's Solution: Uses, Side Effects & Dosage". MedicineNet . WebMD . Retrieved 26 May 2023.
  14. ↑ Williams EL, Hildebrand KL, McCormick SA, Bedel MJ (May 1999). "The effect of intravenous lactated Ringer's solution versus 0.9% sodium chloride solution on serum osmolality in human volunteers". Anesthesia and Analgesia. 88 (5): 999–1003. doi: 10.1213/00000539-199905000-00006 . PMID   10320158.
  15. ↑ Kaplan LJ, Frangos S (April 2005). "Clinical review: Acid-base abnormalities in the intensive care unit -- part II" (PDF). Critical Care. 9 (2). London, England: 198–203. doi: 10.1186/cc2912 . PMC   1175905 . PMID   15774078.
  16. ↑ "Ringer's Solutions". Biological Bulletin Compendia Notes. Marine Biological Laboratory. Retrieved 10 June 2018.
  17. ↑ Manivasagam G, Dhinasekaran D, Rajamanickam A (May 2010). "Biomedical implants: corrosion and its prevention-a review". Recent Patents on Corrosion Science. 2 (1). doi: 10.2174/1877610801002010040 . Retrieved 10 June 2018– via ResearchGate. Table 3. Composition of Ringer's Solution
  18. ↑ "Search Results lactated ringer". DailyMed . U.S. National Library of Medicine. Archived from the original on 25 February 2012.
  19. ↑ Miller DJ (March 2004). "Sydney Ringer; physiological saline, calcium and the contraction of the heart". The Journal of Physiology. 555 (Pt 3): 585–587. doi:10.1113/jphysiol.2004.060731. PMC   1664856 . PMID   14742734.
  20. ↑ White SA, Goldhill DR (May 1997). "Is Hartmann's the solution?". Anaesthesia. 52 (5): 422–427. doi: 10.1111/j.1365-2044.1997.090-az0082.x . PMID   9165959. S2CID   22819554.
  21. ↑ Kraut JA, Madias NE (December 2014). "Lactic acidosis". The New England Journal of Medicine. 371 (24): 2309–2319. doi:10.1056/NEJMra1309483. PMID   25494270.
  22. ↑ Davis H, Jensen T, Johnson A, Knowles P, Meyer R, Rucinsky R, Shafford H (2013). "2013 AAHA/AAFP fluid therapy guidelines for dogs and cats" (PDF). Journal of the American Animal Hospital Association. 49 (3): 149–59. doi:10.5326/JAAHA-MS-5868. PMID   23645543.
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