View source for Ringer's lactate solution

{{Short description|Fluid used for resuscitation after blood loss}}
{{Use dmy dates|date=December 2019}}
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| caption           = A bottle of Ringer's lactate solution
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| DailyMedID        = Ringers
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| synonyms          = compound sodium lactate, sodium lactate solution, Hartmann's solution, Ringer-Locke's solution, Ringer-lactate, lactated Ringer's solution (LRS)
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<!-- Definition and medical uses -->
'''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]].<ref name=BNF69>{{cite book|title=British national formulary: BNF 69|date=2015|publisher=British Medical Association|isbn=9780857111562|page=683|edition=69}}</ref> It is used for replacing fluids and [[electrolytes]] in those who have [[hypovolemia|low blood volume]] or [[low blood pressure]].<ref name=UK2013/> It may also be used to treat [[metabolic acidosis]] and to wash the eye following a [[chemical burn]].<ref name=UK2013/><ref name=Kr2000/> It is given by [[intravenous infusion]] or applied to the affected area.<ref name=UK2013>{{cite web|title=Compound Sodium Lactate Solution for Infusion - Summary of Product Characteristics (SPC) - (eMC) |url=https://www.medicines.org.uk/emc/medicine/30160|website=www.medicines.org.uk|access-date=14 January 2017|date=February 2013|url-status=live|archive-url=https://web.archive.org/web/20170116162825/https://www.medicines.org.uk/emc/medicine/30160|archive-date=16 January 2017}}</ref><ref name=Kr2000>{{cite book| vauthors = Krieglstein GK |title=Atlas of Ophthalmology|date=2000|publisher=Springer Science & Business Media|isbn=9783540780694|page=377|url=https://books.google.com/books?id=LDt1i7BaBA4C&pg=PA377|language=en|url-status=live|archive-url=https://web.archive.org/web/20170116165721/https://books.google.ca/books?id=LDt1i7BaBA4C&pg=PA377|archive-date=2017-01-16}}</ref>

<!-- Side effect and mechanism -->
Side effects may include [[allergic reactions]], [[high blood potassium]], [[hypervolemia]], and [[high blood calcium]].<ref name=UK2013/> It may not be suitable for mixing with certain medications and some recommend against use in the same infusion as a [[blood transfusion]].<ref name=ICU2012/> Ringer's lactate solution has a lower rate of [[hyperchloremic acidosis|acidosis]] as compared with [[normal saline]].<ref name=BNF69/><ref name=ICU2012/> Use is generally safe in [[pregnancy]] and [[breastfeeding]].<ref name=UK2013/> Ringer's lactate solution is in the [[Volume expander#Crystalloids|crystalloid]] family of medications.<ref>{{cite book| vauthors = Saade GR, Foley MR, Phelan III JP, Dildy GA |title=Critical Care Obstetrics|date=2010|publisher=John Wiley & Sons|isbn=9781444396140|page=70|url=https://books.google.com/books?id=Jw8Fl5XF4McC&pg=PA70|language=en|url-status=live|archive-url=https://web.archive.org/web/20170116170237/https://books.google.ca/books?id=Jw8Fl5XF4McC&pg=PA70|archive-date=2017-01-16}}</ref> It is isotonic, i.e. it has the [[Tonicity#Isotonicity|same tonicity]] as [[blood]].<ref name=UK2013/>

<!-- History and culture -->
[[Ringer's solution]] was invented in the 1880s; lactate was added in the 1930s.<ref name=ICU2012>{{cite book| vauthors = Marino PL, Sutin KM |title=The ICU Book |date=2012 |publisher=Lippincott Williams & Wilkins |isbn=9781451161557|page=363|edition=3rd |url=https://books.google.com/books?id=RAk9ai42yjMC&pg=PT363|language=en|url-status=live|archive-url=https://web.archive.org/web/20170918184101/https://books.google.com/books?id=RAk9ai42yjMC&pg=PT363|archive-date=2017-09-18}}</ref> It is on the [[WHO Model List of Essential Medicines|World Health Organization's List of Essential Medicines]].<ref name="WHO21st">{{cite book | vauthors = ((World Health Organization)) | title = World Health Organization model list of essential medicines: 21st list 2019 | year = 2019 | hdl = 10665/325771 | author-link = World Health Organization | publisher = World Health Organization | location = Geneva | id = WHO/MVP/EMP/IAU/2019.06. License: CC BY-NC-SA 3.0 IGO | hdl-access=free }}</ref> Lactated Ringer's is available as a [[Generic drug|generic medication]].<ref name="BNF69"/>  For people with  [[liver failure|liver dysfunction]], Ringer's acetate may be a better alternative with the lactate replaced by [[acetate]].<ref>{{cite book| vauthors = Marino PL |title=Marino's The ICU Book|date=2013|publisher=Lippincott Williams & Wilkins|isbn=9781469831640|page=223|edition=4|url=https://books.google.com/books?id=XMaMAgAAQBAJ&q=The%20ICU%20book&pg=PA223|language=en|url-status=live|archive-url=https://web.archive.org/web/20170116170418/https://books.google.ca/books?id=XMaMAgAAQBAJ&lpg=PP1&dq=The%20ICU%20book&pg=PA223|archive-date=2017-01-16}}</ref> In [[Scandinavia]] Ringer's acetate is typically used.<ref>{{Cite web|url=http://www.vgregion.se/upload/SkaS/SRV/AT/at-forelasning-vatsketerapi.pdf|title=''Vätsketerapi för AT/ST läkare KSS'' — 'Rehydration therapy for interns and specialists, KSS'| vauthors = Bjarby J |publisher=Västragötalandsregionen|access-date=13 January 2017|url-status=live|archive-url=https://web.archive.org/web/20170116171932/http://www.vgregion.se/upload/SkaS/SRV/AT/at-forelasning-vatsketerapi.pdf|archive-date=16 January 2017}}</ref>

== Medical uses ==

Ringer's lactate solution is commonly used for [[Fluid replacement|fluid resuscitation]] after [[blood loss]] due to [[Physical trauma|trauma]], or [[surgery]].<ref name="PestanaFifth">{{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)"}}</ref><ref name = "Singh_2021">{{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" }}</ref>

It is extensively used in aggressive volume resuscitation, e.g. for patients with pancreatitis, [[hemorrhagic shock]] or [[burn injury|major burn injuries]].<ref name = "Singh_2021" /> Since the lactate is converted into [[bicarbonate]], caution should be used as patients may become [[alkalosis|alkalotic]].<ref>{{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}}</ref> In [[metabolic acidosis|acidotic]] states, such as in acute kidney failure, Ringer's lactate solution may be advantageous as the byproducts of [[Cori cycle|lactate metabolism]] in the liver counteract the [[acidosis]].<ref name=dailymed_package_insert/> In a large-volume resuscitation over several hours, Ringer's lactate solution maintains a more stable [[blood pH]] than normal saline.<ref name="ICU2012" />

Ringer's lactate and other crystalloid fluids are also used as vehicles for the intravenous (IV) delivery of medications.<ref name = "Singh_2021" />

== Chemistry ==
One liter of Ringer's lactate solution contains:<ref>{{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}}</ref>
* 130–131 [[milliequivalent|mEq]] of [[sodium]] [[ion]] = 130&nbsp;[[Molarity#Molarity|mmol&nbsp;L<sup>−1</sup>]]
* 109–111 mEq of [[chloride]] ion = 109&nbsp;mmol&nbsp;L<sup>−1</sup>
* 28–29 mEq of [[lactic acid|lactate]] ion = 28&nbsp;mmol&nbsp;L<sup>−1</sup>
* 4–5 mEq of [[potassium]] ion = 4&nbsp;mmol&nbsp;L<sup>−1</sup>
* 2–3 mEq of [[calcium]] ion = 1.5&nbsp;mmol&nbsp;L<sup>−1</sup>

Ringer's lactate has an [[osmolarity]] of 273&nbsp;mOsm&nbsp;L<sup>−1</sup><ref name=williams_1999/> and a pH of 6.5.<ref name = "Singh_2021" /> 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.<ref name=acidbaseabnormalities/>

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.<ref name=ICU2012/>

Generally, the source of the constituent ions is a mixture of [[sodium chloride]] (NaCl), [[sodium lactate]] (CH<sub>3</sub>CH(OH)CO<sub>2</sub>Na), [[calcium chloride]] (CaCl<sub>2</sub>), 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]] (MgCl<sub>2</sub>).<ref>{{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}}</ref><ref>{{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 }}</ref>

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.<ref name=dailymed/>
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== History ==
Ringer's saline solution was invented in the early 1880s by [[Sydney Ringer]],<ref name=ICU2012/> 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.<ref name=miller_2004/> The use of Ringer's original solution of inorganic salts slowly became more popular.<ref name=ICU2012/> In the 1930s, the original solution was further modified by American pediatrician [[Alexis Hartmann]] for the purpose of treating [[acidosis]]. Hartmann added [[Lactic acid|lactate]], which mitigates changes in [[pH]] by acting as a [[Buffering agent|buffer]] for acid. Thus the solution became known as "Ringer's lactate solution" or "Hartmann's solution".<ref name=ICU2012/><ref name=white_1997/>
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==Formulations==
[[Ringer's solution]] technically refers only to the saline component, without [[lactic acid|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.<ref>{{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 }}</ref> 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}}

== 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 [[Subcutaneous tissue#Injection|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.<ref name="AAHA/AAFP_Fluid_Therapy_Guidelines">{{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 }}</ref>

== See also ==
* [[Banana bag]]
* [[Intravenous therapy]]
* [[Oral rehydration therapy]]
* [[Phosphate buffered saline]] (cell culture)
* [[Tyrode's solution]]

== References ==
{{Reflist|32em|refs=

<ref name=williams_1999>{{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 }}</ref>

<ref name=dailymed>{{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 }}</ref>

<ref name=miller_2004>{{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 }}</ref>

<ref name=white_1997>{{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 }}</ref>

<ref name=dailymed_package_insert>{{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 }}</ref>

<ref name=acidbaseabnormalities>{{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 }}</ref>

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== External links ==
* {{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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[[Category:Blood substitutes]]
[[Category:Intravenous fluids]]
[[Category:World Health Organization essential medicines]]
[[Category:Wikipedia medicine articles ready to translate]]