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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 chloride , commonly known as Salt#Edible salt, edible salt, is an ionic compound with the chemical formula NaCl, representing a 1:1 ratio of sodium and chloride ions. It is transparent or translucent, brittle, hygroscopic, and occurs a ...
, sodium lactate, potassium chloride, and calcium chloride in
water Water is an inorganic compound with the chemical formula . It is a transparent, tasteless, odorless, and Color of water, nearly colorless chemical substance. It is the main constituent of Earth's hydrosphere and the fluids of all known liv ...
. It is used for replacing fluids and
electrolytes An electrolyte is a substance that conducts electricity through the movement of ions, but not through the movement of electrons. This includes most soluble salts, acids, and bases, dissolved in a polar solvent like water. Upon dissolving, t ...
in those who have low blood volume or low blood pressure. It may also be used to treat metabolic acidosis and to wash the eye following a chemical burn. It is given by intravenous infusion or applied to the affected area. Side effects may include allergic reactions, high blood potassium,
hypervolemia Hypervolemia, also known as fluid overload, is the medical condition where there is too much fluid in the blood. The opposite condition is hypovolemia, which is too little fluid volume in the blood. Fluid volume excess in the intravascular compa ...
, and high blood calcium. It may not be suitable for mixing with certain medications and some recommend against use in the same infusion as a blood transfusion. Ringer's lactate solution has a lower rate of acidosis as compared with normal saline. Use is generally safe in
pregnancy Pregnancy is the time during which one or more offspring gestation, gestates inside a woman's uterus. A multiple birth, multiple pregnancy involves more than one offspring, such as with twins. Conception (biology), Conception usually occurs ...
and
breastfeeding Breastfeeding, also known as nursing, is the process where breast milk is fed to a child. Infants may suck the milk directly from the breast, or milk may be extracted with a Breast pump, pump and then fed to the infant. The World Health Orga ...
. Ringer's lactate solution is in the crystalloid family of medications. It is isotonic, i.e. it has the same tonicity as
blood Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood is com ...
. Ringer's solution was invented in the 1880s; lactate was added in the 1930s. It is on the World Health Organization's List of Essential Medicines. Lactated Ringer's is available as a
generic medication A generic drug is a pharmaceutical drug that contains the same chemical substance as a drug that was originally protected by chemical patents. Generic drugs are allowed for sale after the patents on the original drugs expire. Because the active ch ...
. For people with liver dysfunction, Ringer's acetate may be a better alternative with the lactate replaced by
acetate An acetate is a salt formed by the combination of acetic acid with a base (e.g. alkaline, earthy, metallic, nonmetallic, or radical base). "Acetate" also describes the conjugate base or ion (specifically, the negatively charged ion called ...
. In
Scandinavia Scandinavia is a subregion#Europe, subregion of northern Europe, with strong historical, cultural, and linguistic ties between its constituent peoples. ''Scandinavia'' most commonly refers to Denmark, Norway, and Sweden. It can sometimes also ...
Ringer's acetate is typically used.


Medical uses

Ringer's lactate solution is commonly used for fluid resuscitation after
blood loss Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, v ...
due to trauma, or
surgery Surgery is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions (e.g., trauma, disease, injury, malignancy), to alter bodily functions (e.g., malabsorption created by bariatric surgery s ...
. 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 In inorganic chemistry, bicarbonate (IUPAC-recommended nomenclature: hydrogencarbonate) is an intermediate form in the deprotonation of carbonic acid. It is a polyatomic anion with the chemical formula . Bicarbonate serves a crucial bioche ...
, caution should be used as patients may become alkalotic. 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.


Chemistry

One liter of Ringer's lactate solution contains: * 130–131 mEq of
sodium Sodium is a chemical element; it has Symbol (chemistry), symbol Na (from Neo-Latin ) and atomic number 11. It is a soft, silvery-white, highly reactive metal. Sodium is an alkali metal, being in group 1 element, group 1 of the peri ...
ion = 130  mmol L−1 * 109–111 mEq of
chloride The term chloride refers to a compound or molecule that contains either a chlorine anion (), which is a negatively charged chlorine atom, or a non-charged chlorine atom covalently bonded to the rest of the molecule by a single bond (). The pr ...
ion = 109 mmol L−1 * 28–29 mEq of lactate ion = 28 mmol L−1 * 4–5 mEq of
potassium Potassium is a chemical element; it has Symbol (chemistry), symbol K (from Neo-Latin ) and atomic number19. It is a silvery white metal that is soft enough to easily cut with a knife. Potassium metal reacts rapidly with atmospheric oxygen to ...
ion = 4 mmol L−1 * 2–3 mEq of
calcium Calcium is a chemical element; it has symbol Ca and atomic number 20. As an alkaline earth metal, calcium is a reactive metal that forms a dark oxide-nitride layer when exposed to air. Its physical and chemical properties are most similar to it ...
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 citric acid cycle—also known as the Krebs cycle, Szent–Györgyi–Krebs cycle, or TCA cycle (tricarboxylic acid cycle)—is a series of chemical reaction, biochemical reactions that release the energy stored in nutrients through acetyl-Co ...
, 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 Sodium chloride , commonly known as Salt#Edible salt, edible salt, is an ionic compound with the chemical formula NaCl, representing a 1:1 ratio of sodium and chloride ions. It is transparent or translucent, brittle, hygroscopic, and occurs a ...
(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). 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.


History

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".


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. Ringers lactate should not cause an elevated blood-lactate level except possibly in the most severe presentations of liver failure.


Veterinary use

It is used for the treatment or palliative care of chronic
kidney failure Kidney failure, also known as renal failure or end-stage renal disease (ESRD), is a medical condition in which the kidneys can no longer adequately filter waste products from the blood, functioning at less than 15% of normal levels. Kidney fa ...
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.


See also

* Banana bag *
Intravenous therapy Intravenous therapy (abbreviated as IV 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 nutr ...
*
Oral rehydration therapy Oral rehydration therapy (ORT) also officially known as Oral Rehydration Solution is a type of fluid replacement used to prevent and treat dehydration, especially due to diarrhea. It involves drinking water with modest amounts of sugar and salt ...
* Phosphate buffered saline (cell culture) * Tyrode's solution


References


External links

* {{portal bar, Medicine Blood substitutes Intravenous fluids World Health Organization essential medicines Wikipedia medicine articles ready to translate