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Ringer's lactate solution (RL), also known as sodium lactate solution, Lactated Ringer’s, and Hartmann's solution, is a mixture of sodium chloride,
sodium lactate Sodium lactate is the sodium salt of lactic acid, and has a mild saline taste. It is produced by fermentation of a sugar source, such as corn or beets, and then, by neutralizing the resulting lactic acid to create a compound having the formula NaC ...
,
potassium chloride Potassium chloride (KCl, or potassium salt) is a metal halide salt composed of potassium and chlorine. It is odorless and has a white or colorless vitreous crystal appearance. The solid dissolves readily in water, and its solutions have a sa ...
, and
calcium chloride Calcium chloride is an inorganic compound, a salt with the chemical formula . It is a white crystalline solid at room temperature, and it is highly soluble in water. It can be created by neutralising hydrochloric acid with calcium hydroxide. Ca ...
in water. It is used for replacing fluids and
electrolytes An electrolyte is a medium containing ions that is electrically conducting through the movement of those ions, but not conducting electrons. This includes most soluble salts, acids, and bases dissolved in a polar solvent, such as water. Upon dis ...
in those who have
low blood volume Hypovolemia, also known as volume depletion or volume contraction, is a state of abnormally low extracellular fluid in the body. This may be due to either a loss of both salt and water or a decrease in blood volume. Hypovolemia refers to the loss ...
or low blood pressure. It may also be used to treat
metabolic acidosis Metabolic acidosis is a serious electrolyte disorder characterized by an imbalance in the body's acid-base balance. Metabolic acidosis has three main root causes: increased acid production, loss of bicarbonate, and a reduced ability of the kidneys ...
and to wash the eye following a
chemical burn A chemical burn occurs when living tissue is exposed to a corrosive substance (such as a strong acid, base or oxidizer) or a cytotoxic agent (such as mustard gas, lewisite or arsine). Chemical burns follow standard burn classification and may ca ...
. It is given by intravenous infusion or applied to the affected area. Side effects may include
allergic reactions Allergies, also known as allergic diseases, refer a number of conditions caused by the hypersensitivity of the immune system to typically harmless substances in the environment. These diseases include hay fever, food allergies, atopic dermati ...
,
high blood potassium Hyperkalemia is an elevated level of potassium (K+) in the blood. Normal potassium levels are between 3.5 and 5.0mmol/L (3.5 and 5.0mEq/L) with levels above 5.5mmol/L defined as hyperkalemia. Typically hyperkalemia does not cause symptoms. Occasi ...
,
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 Hypercalcemia, also spelled hypercalcaemia, is a high calcium (Ca2+) level in the blood serum. The normal range is 2.1–2.6  mmol/L (8.8–10.7 mg/dL, 4.3–5.2 mEq/L), with levels greater than 2.6 mmol/L defined as hypercalce ...
. It may not be suitable for mixing with certain medications and some recommend against use in the same infusion as a
blood transfusion Blood transfusion is the process of transferring blood products into a person's circulation intravenously. Transfusions are used for various medical conditions to replace lost components of the blood. Early transfusions used whole blood, but mo ...
. Ringer's lactate solution has a lower rate of
acidosis Acidosis is a process causing increased acidity in the blood and other body tissues (i.e., an increase in hydrogen ion concentration). If not further qualified, it usually refers to acidity of the blood plasma. The term ''acidemia'' describes ...
as compared with
normal saline Saline (also known as saline solution) 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 ...
. Use is generally safe in pregnancy and
breastfeeding Breastfeeding, or nursing, is the process by which human breast milk is fed to a child. Breast milk may be from the breast, or may be expressed by hand or pumped and fed to the infant. The World Health Organization (WHO) recommends that brea ...
. Ringer's lactate solution is in the crystalloid family of medications. It is isotonic, i.e. it has the same tonicity as blood. 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. For people with
liver dysfunction Liver disease, or hepatic disease, is any of many diseases of the liver. If long-lasting it is termed chronic liver disease. Although the diseases differ in detail, liver diseases often have features in common. Signs and symptoms Some of the sig ...
, 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 an ...
. In Scandinavia Ringer's acetate is typically used.


Medical uses

Ringer's lactate solution is commonly used for
fluid resuscitation 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 ...
after blood loss due to
trauma Trauma most often refers to: *Major trauma, in physical medicine, severe physical injury caused by an external source *Psychological trauma, a type of damage to the psyche that occurs as a result of a severely distressing event *Traumatic inju ...
, surgery, or a
burn injury A burn is an injury to skin, or other tissues, caused by heat, cold, electricity, chemicals, friction, or ultraviolet radiation (like sunburn). Most burns are due to heat from hot liquids (called scalding), solids, or fire. Burns occur mainl ...
(i.e. in hemorrhagic shock). Ringer's lactate solution is used because the byproducts of lactate metabolism in the liver counteract
acidosis Acidosis is a process causing increased acidity in the blood and other body tissues (i.e., an increase in hydrogen ion concentration). If not further qualified, it usually refers to acidity of the blood plasma. The term ''acidemia'' describes ...
, which is a chemical imbalance that occurs with acute fluid loss or kidney failure. In a large-volume resuscitation over several hours, Ringer's lactate solution maintains a more stable
blood pH 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 in the cir ...
than normal saline. The intravenous dose of Ringer's lactate solution is usually calculated by estimated fluid loss and presumed fluid deficit. For fluid resuscitation the usual rate of administration is 20 to 30 mL/kg body weight/hour. RL is not suitable for maintenance therapy (i.e., maintenance fluids) because the sodium content (130 mEq/L) is considered too low, particularly for children, and the potassium content (4 mEq/L) is too low, in view of electrolyte daily requirement. Moreover, 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 biochemic ...
, long-term use will cause patients to become alkalotic. Ringer's lactate and other crystalloids are also used as vehicles for the IV delivery of medications.


Chemistry

One liter of Ringer's lactate solution contains: * 130–131
mEq An equivalent (symbol: officially equiv; unofficially but often Eq) is the amount of a substance that reacts with (or is ''equivalent'' to) an arbitrary amount (typically one mole) of another substance in a given chemical reaction. It is an arch ...
of sodium
ion An ion () is an atom or molecule with a net electrical charge. The charge of an electron is considered to be negative by convention and this charge is equal and opposite to the charge of a proton, which is considered to be positive by conv ...
= 130  mmol L−1 * 109–111 mEq of
chloride The chloride ion is the anion (negatively charged ion) Cl−. It is formed when the element chlorine (a halogen) gains an electron or when a compound such as hydrogen chloride is dissolved in water or other polar solvents. Chloride salts ...
ion = 109 mmol L−1 * 28–29 mEq of
lactate Lactate may refer to: * Lactation, the secretion of milk from the mammary glands * Lactate, the conjugate base of lactic acid Lactic acid is an organic acid. It has a molecular formula . It is white in the solid state and it is miscible with w ...
ion = 28 mmol L−1 * 4–5 mEq of potassium ion = 4 mmol L−1 * 2–3 mEq of
calcium Calcium is a chemical element with the 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 ...
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 (CAC)—also known as the Krebs cycle or the TCA cycle (tricarboxylic acid cycle)—is a series of chemical reactions to release stored energy through the oxidation of acetyl-CoA derived from carbohydrates, fats, and protei ...
, 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 Sodium lactate is the sodium salt of lactic acid, and has a mild saline taste. It is produced by fermentation of a sugar source, such as corn or beets, and then, by neutralizing the resulting lactic acid to create a compound having the formula NaC ...
(CH3CH(OH)CO2Na),
calcium chloride Calcium chloride is an inorganic compound, a salt with the chemical formula . It is a white crystalline solid at room temperature, and it is highly soluble in water. It can be created by neutralising hydrochloric acid with calcium hydroxide. Ca ...
(CaCl2), and
potassium chloride Potassium chloride (KCl, or potassium salt) is a metal halide salt composed of potassium and chlorine. It is odorless and has a white or colorless vitreous crystal appearance. The solid dissolves readily in water, and its solutions have a sa ...
(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 Acidosis is a process causing increased acidity in the blood and other body tissues (i.e., an increase in hydrogen ion concentration). If not further qualified, it usually refers to acidity of the blood plasma. The term ''acidemia'' describes ...
. Hartmann added
lactate Lactate may refer to: * Lactation, the secretion of milk from the mammary glands * Lactate, the conjugate base of lactic acid Lactic acid is an organic acid. It has a molecular formula . It is white in the solid state and it is miscible with w ...
, which mitigates changes in pH by acting as a
buffer Buffer may refer to: Science * Buffer gas, an inert or nonflammable gas * Buffer solution, a solution used to prevent changes in pH * Buffering agent, the weak acid or base in a buffer solution * Lysis buffer, in cell biology * Metal ion 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 Lactate may refer to: * Lactation, the secretion of milk from the mammary glands * Lactate, the conjugate base of lactic acid Lactic acid is an organic acid. It has a molecular formula . It is white in the solid state and it is miscible with w ...
. 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 Palliative care (derived from the Latin root , or 'to cloak') is an interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex, and often terminal illnesses. Wit ...
of chronic kidney failure in small animals. The solution can be administered intravenously or
subcutaneously The subcutaneous tissue (), also called the hypodermis, hypoderm (), subcutis, superficial fascia, is the lowermost layer of the integumentary system in vertebrates. The types of cells found in the layer are fibroblasts, adipose cells, and macro ...
. 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

* Intravenous therapy *
Oral rehydration therapy Oral rehydration therapy (ORT) 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 salts, specifically sodium and potassium. Oral rehydrat ...
* 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