Lactated Ringers (LR) vs Normal Saline (NS) - Comparison



Composition of LR:

 • Sodium 130 mEq/L

 • Potassium 4 mEq/L

 • Calcium 1.5 mEq/L

 • Chloride 109 mEq/L

 • Sodium lactate 28 mEq/L

 • Osmolarity of 273 mOsmol/L

 • pH of 6.5

 • Caloric content of 9 kcal/L



Composition of NS:

 • Sodium 154 mEq/L

 • Chloride 154 mEq/L

 • Osmolarity 308 mOsmol/L

 • pH of 4-7.5



Lactated Ringers (LR)

 • pH 6.5

 • SMART/SALT-ED trial

 • Minimal K - 4 mEq

 • Sodium Lactate: 28 mole/L of sodium lactate NOT lactic acid

 • LR Contains Calcium:

	- Can give with blood but not in same line

	- Citrate in blood can precipitate with calcium causing clotting

 • Higher pH:

	- Less development of metabolic acidosis

	- Protective effects with less inflammation and necrosis in states such as acute pancreatitis



Normal Saline (NS) Is Not Normal!

 • pH 4 to 7.5

 • Saline Exacerbates Acidosis:

	- Hyperchloremia nonanion gap metabolic acidosis

 • Saline Is Dangerous in Hyperkalemia:

	- Acidosis worsening transcellular shift

 • Saline Causes AKI:

	- Tubuloglomerular feedback: Macula densa receives high chloride load - signal to reduce GFR to reduce chloride filtration

	- Renal edema and capsular stretch - decreased renal blood flow and renal tissue perfusion

	- Decreased GFR, urine volume and sodium excretion

 • Saline May Cause Hemodynamic Instability:

	- Renal vasoconstriction and vasodilation

	- Acidosis worsens cardiac contractility

 • Saline Increases Levels of Inflammation

 • Increases Edema:

	- Increases vascular permeability and vasodilation

	- Damage to endothelial glycocalyx - increases interstitial volume - increased edema

 • Coagulopathy:

	- Dilutes clotting factors - impair coagulation and hemostasis:

	- Iatrogenic coagulopathy - functional impairment of thrombin and fibrin

	- Also can disrupt and destroy existing clots



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