Ringer's lactate solution

Ringer's lactate solution is commonly used for fluid resuscitation after blood loss due to trauma, or surgery.{{cite book | vauthors = Pestana C |title=Pestana's Surgery Notes |date=7 April 2020 |publisher=Kaplan Medical Test Prep |isbn=978-1506254340 |pages=4–5 |edition=Fifth |quote="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)"}}{{cite book | vauthors = Singh S, Kerndt CC, Davis D | chapter = Ringer's Lactate | title = StatPearls | date = 2021 | pmid = 29763209 | chapter-url = https://www.ncbi.nlm.nih.gov/books/NBK500033/ | access-date = 14 July 2021 | location = Treasure Island (FL) | publisher = StatPearls Publishing | quote = "Ringer’s lactate is largely used in aggressive volume resuscitation from blood loss or burn injuries" }}

It is extensively used in aggressive volume resuscitation, e.g. for patients with pancreatitis, hemorrhagic shock or major burn injuries. Since the lactate is converted into bicarbonate, caution should be used as patients may become alkalotic.{{cite web|url=http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=d3d29c8f-c326-4097-814a-7f4e08c67068 |title= Human Prescription Drug Label: Lactated Ringers (sodium chloride, sodium lactate, potassium chloride, and calcium chloride) injection, solution | author = B. Braun Medical Inc. | work = DailyMed | publisher = U.S. National Library of Medicine |quote=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.|url-status=live|archive-url=https://web.archive.org/web/20140826120818/http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=d3d29c8f-c326-4097-814a-7f4e08c67068|archive-date=2014-08-26}} 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. In a large-volume resuscitation over several hours, Ringer's lactate solution maintains a more stable blood pH than normal saline.

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

One liter of Ringer's lactate solution contains:{{cite web |url=https://www.medicinenet.com/ringers-lactated_ringers_solution-intravenous/article.htm |title=Lactated Ringer's Solution: Uses, Side Effects & Dosage | vauthors = Ogbru D | veditors = Davis CP |date=2022-10-21 |work=MedicineNet |publisher=WebMD |access-date=2023-05-26}}

• 130–131 mEq of sodium ion = 130 mmol L⁻¹
• 109–111 mEq of chloride ion = 109 mmol L⁻¹
• 28–29 mEq of lactate ion = 28 mmol L⁻¹
• 4–5 mEq of potassium ion = 4 mmol L⁻¹
• 2–3 mEq of calcium ion = 1.5 mmol L⁻¹

Ringer's lactate has an osmolarity of 273 mOsm L⁻¹ and a pH of 6.5. 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.

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.

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).{{cite web | work = Biological Bulletin Compendia Notes | volume = Part B | title = Ringer's Solutions |url=http://comm.archive.mbl.edu/BiologicalBulletin/COMPENDIUM/Comp-RGRNotes.html | publisher = Marine Biological Laboratory |access-date=10 June 2018}}{{cite journal | vauthors = Manivasagam G, Dhinasekaran D, Rajamanickam A | title = Biomedical implants: corrosion and its prevention-a review. | journal = Recent Patents on Corrosion Science | date = May 2010 | volume = 2 | issue = 1 | doi = 10.2174/1877610801002010040 |url=https://www.researchgate.net/figure/Composition-of-Ringers-Solution_tbl3_229066650 | via =ResearchGate |access-date=10 June 2018 | quote = Table 3. Composition of Ringer's Solution | doi-access = free }}

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.

Ringer's saline solution was invented in the early 1880s by Sydney Ringer, 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. The use of Ringer's original solution of inorganic salts slowly became more popular. 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".

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.{{cite journal | vauthors = Kraut JA, Madias NE | title = Lactic acidosis | journal = The New England Journal of Medicine | volume = 371 | issue = 24 | pages = 2309–2319 | date = December 2014 | pmid = 25494270 | doi = 10.1056/NEJMra1309483 }} Ringers lactate should not cause an elevated blood-lactate level except possibly in the most severe presentations of liver failure.{{citation needed|date=December 2021}}

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.{{cite journal | vauthors = Davis H, Jensen T, Johnson A, Knowles P, Meyer R, Rucinsky R, Shafford H | title = 2013 AAHA/AAFP fluid therapy guidelines for dogs and cats | journal = Journal of the American Animal Hospital Association | volume = 49 | issue = 3 | pages = 149–59 | date = 2013 | pmid = 23645543 | doi = 10.5326/JAAHA-MS-5868 | url = https://www.aaha.org/globalassets/02-guidelines/fluid-therapy/fluid_therapy_guidelines.pdf }}

• Banana bag
• Intravenous therapy
• Oral rehydration therapy
• Phosphate buffered saline (cell culture)
• Tyrode's solution

{{Reflist|32em|refs=

{{cite journal | vauthors = Williams EL, Hildebrand KL, McCormick SA, Bedel MJ | title = The effect of intravenous lactated Ringer's solution versus 0.9% sodium chloride solution on serum osmolality in human volunteers | journal = Anesthesia and Analgesia | volume = 88 | issue = 5 | pages = 999–1003 | date = May 1999 | pmid = 10320158 | doi = 10.1213/00000539-199905000-00006 | doi-access = free }}

{{Cite web|url=https://dailymed.nlm.nih.gov/dailymed/search.cfm?startswith=lactated+ringer&x=0&y=0|archive-url=https://web.archive.org/web/20120225073029/http://dailymed.nlm.nih.gov/dailymed/search.cfm?startswith=lactated+ringer&x=0&y=0|url-status=dead| title = Search Results lactated ringer|archive-date=25 February 2012|work = DailyMed | publisher = U.S. National Library of Medicine }}

{{cite journal | vauthors = Miller DJ | title = Sydney Ringer; physiological saline, calcium and the contraction of the heart | journal = The Journal of Physiology | volume = 555 | issue = Pt 3 | pages = 585–587 | date = March 2004 | pmid = 14742734 | pmc = 1664856 | doi = 10.1113/jphysiol.2004.060731 }}

{{cite journal | vauthors = White SA, Goldhill DR | title = Is Hartmann's the solution? | journal = Anaesthesia | volume = 52 | issue = 5 | pages = 422–427 | date = May 1997 | pmid = 9165959 | doi = 10.1111/j.1365-2044.1997.090-az0082.x | s2cid = 22819554 | doi-access = free }}

{{Cite web|url=https://dailymed.nlm.nih.gov/dailymed/index.cfm|archive-url=https://web.archive.org/web/20100306105736/http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=7535|url-status=dead|title=Lactated Ringer's (sodium chloride, sodium lactate, potassium chloride and calcium chloride) Injection|archive-date=6 March 2010| work = DailyMed | publisher = U.S. National Library of Medicine }}

{{cite journal | vauthors = Kaplan LJ, Frangos S | title = Clinical review: Acid-base abnormalities in the intensive care unit -- part II | journal = Critical Care | location = London, England | volume = 9 | issue = 2 | pages = 198–203 | date = April 2005 | pmid = 15774078 | pmc = 1175905 | doi = 10.1186/cc2912 | url = http://crashingpatient.com/wp-content/pdf/acidbase/acid%20base%20in%20the%20icu.pdf | doi-access = free }}

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• {{cite web| url = https://druginfo.nlm.nih.gov/drugportal/name/Ringer's%20lactate | publisher = U.S. National Library of Medicine| work = Drug Information Portal| title = Ringer's lactate }}

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