Ringers VS Normal saline.pptx

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 Crystalloids (Normal saline vs ringers sol.)

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). Normal Saline (NS)

3. 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 . Ringer’s Solutions

4. 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. Guiding principles governing the use of maintenance fluids such as Ringer’s solutions (when its ideal to use ringers as preoperative IV fluids)

5. 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. Ringers solutions, Properties & Differences

6. 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. Ringers solutions, Properties & differences

7. 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. Ringers solutions, Properties & differences

8. 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. D iazepam , Ketamine , Lorazepam & Propofol. Phenytoin. Preserved blood with citrate anticoagulant ( theoretical risk of coagulation, use a separate line/ alternative IV fluid). Avoid Ringers solutions with

9. 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]. Quoted Pearls: Ringers (Lactate) Vs Normal Saline

10. 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 .. Quoted Pearls: Ringers (Lactate) Vs Normal Saline

11. 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%). Quoted Pearls: Ringer (Lactate) Vs Normal Saline

12. 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. Quoted Pearls: Ringer (Lactate) Vs Normal Saline

13. Jennifer Whitlock. Lactated Ringer’s Solution vs. Normal Saline. Verywellhealth website. 24 th May 2022. Bradley A. Boucher and G. Christopher Wood. Cahpter 13: Hypovolumic shock. Pharmacotherapy principles and practice. MacGraw Hill Education 5 th 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. References

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