Comparison of Lactated Ringers (LR) vs Normal Saline ...

Comparison of Lactated Ringers (LR) vs Normal Saline (NS)
NS can cause coagulopathy:
 - NS dilutes clotting factors → impairing coagulation and hemostasis.
 - NS can cause a functional impairment of thrombin and fibrinogen
 - ↑ disruption of existing clots.
 - acidic milieu can also ↓ clot formation/stability
In Traumatology NS can lead to: compartment syndrome, dilutional coagulopathy, hyperchloremic metabolic acidosis, immune dysfunction
Increasing edema:
 - NS can increase vascular permeability driving leak of proteins into the interstitial compartment 
 - can drive the dilatation of vessels → increase cardiovascular stress 
 - NS can also ↑ interstitial edema
 - only 20% of infused NS remains intravascular
↑ disruption to the vascular endothelial layer by NS induced acidosis: This is a mechanism explained in animal models where the endothelial glycocalyx is disrupted resulting in more edema. Crystalloids damage EGL layer and worsen edema.
NS induced acidosis can impair cardiac contractility and also decrease BP. That may account for a precipitous drop in BP soon after a temporary recovery of BP with a bolus. This can also be attributed to distribution of fluids across compartments including the interstitium.
Saline causes hemodynamic instability: ↑ vasodilation and in this small study ( ) there was a finding that patients receiving NS required vasopressors more frequently.
↑ Inflammation with NS:
 - LR favored in acute pancreatitis - NS can worsen inflammation and necrosis in this condition. Patients with acute pancreatitis had a no significant trend towards higher SIRS
 - higher levels of CRP/ other pro-inflammatory cytokines with NS
Inflammation ↓ with LR: In vitro, LR inhibited the induction of inflammatory phenotype of macrophages and NF-κB activation. This effect was not observed when using Ringer's solution without lactate, suggesting a direct anti-inflammatory effect of lactate

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Contributed by

Dr. Ravi Singh K
Academic Hospitalist and APD @SinaiBmoreIMRes, Clinical reasoning,Simulation and POCUS enthusiast -
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