Bedside Snapshot
- Use It For
- Sepsis and septic shock; hypovolemia and dehydration; thermal burn resuscitation; DKA, pancreatitis and perioperative fluid replacement
- Adult Dose
- Sepsis: ≥30 mL/kg IV in the first 3 hr, as boluses with reassessment
- Thermal burns ≥20% TBSA: 2 mL/kg/%TBSA over 24 hr from injury, half in first 8 hr; titrate to urine output
- DKA: 500–1,000 mL/hr IV for the first 2–4 hr
- Pediatric Dose
- Shock: 10–20 mL/kg IV/IO bolus, reassess after each (up to 40–60 mL/kg in the first hr with intensive care, SSC Children 2026, conditional). Burns >15% TBSA (some protocols ≥10%): burn-center formula plus maintenance
- Onset / Duration
- IV/IO: immediate / volume-based; about one-quarter of a bolus stays intravascular once it equilibrates
- Do Not Give / Hold If
- Neonates on ceftriaxone; same set as citrated blood; severe TBI or raised ICP (use 0.9% saline); new crackles or falling SpO₂
- Watch For
- Fluid overload (crackles, falling SpO₂); hyponatremia (confusion, Na⁺); hyperkalemia in renal failure (K⁺, ECG); alkalosis after large volumes (HCO₃⁻)
- Reversal / Rescue
- No antidote: stop the infusion. Overload: sit up, oxygen, CPAP or ventilation, diuretic. Persistent shock: vasopressor or blood, not more crystalloid
- Must Remember
- Crystalloid is a bridge, not a cure: reassess after every bolus, switch to blood for hemorrhage and vasopressors for persistent septic shock; never run with ceftriaxone or citrated blood
Indications
Emergency & Prehospital
- Sepsis-induced hypoperfusion or septic shock: the first-line crystalloid. Balanced crystalloid is suggested over 0.9% saline in adults and children. That is a conditional call, with very low certainty in children.
- Hypovolemia and dehydration: vomiting, diarrhea, heat illness and other extracellular fluid losses
- Thermal burns: the default burn resuscitation crystalloid. Adults at ≥20% TBSA. Children at >15% TBSA, or ≥10% in some burn-center protocols.
- Hemorrhagic shock: a small-volume bridge, and only until blood products are available.
ED / ICU / Transport
- Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state: the initial fluid. It is isotonic, either balanced crystalloid or 0.9% saline.
- Acute pancreatitis: moderate-rate fluid resuscitation. LR is the usual fluid.
- Critically ill adults needing fluid: the default is a balanced crystalloid (lactated Ringer's or Plasma-Lyte A), sepsis included. Surviving Sepsis Campaign 2026 suggests balanced fluid over 0.9% saline. Use 0.9% saline instead for traumatic brain injury or raised ICP. In an individual-patient meta-analysis of 6 ICU trials, in-hospital death in TBI was 19.1% with balanced fluid, against 14.7%. Crush injury is another case (NASEMSO 2022: avoid lactated Ringer's). And when hyperkalemia is a risk, the LR label says avoid it.
- Interfacility transfer: kept running during transfer, as resuscitation or maintenance fluid.
Other Uses
- Perioperative and maintenance fluid: the labeled source of water and electrolytes in adults and children. Glucose and extra potassium must be added or given separately.
- Alkalinizing agent: a labeled indication, since lactate is converted to bicarbonate. The container label says it is not for use in treating lactic acidosis.
- Carrier fluid: it carries compatible IV drugs. Check compatibility for each drug and consult pharmacy.
- Not preferred: severe traumatic brain injury (TBI) or raised intracranial pressure (ICP), including sepsis with TBI. Reach for 0.9% saline. Crush injury: NASEMSO specifies 0.9% saline before release, because LR contains potassium.
Composition
| Component | Per Liter | Comparison to Plasma |
|---|---|---|
| Na⁺ | 130 mEq | 135–145 mEq/L: slightly lower |
| Cl⁻ | 109 mEq | 96–106 mEq/L: close (0.9% saline has 154) |
| K⁺ | 4 mEq | 3.5–5 mEq/L: similar |
| Ca²⁺ | 2.7 mEq (about 1.4 mmol) | Lower than serum total calcium; enough to clot citrated blood in the line |
| Buffer | Lactate 28 mEq (as sodium lactate) | Metabolized to bicarbonate (plasma HCO₃⁻ 22–28 mEq/L) |
| Mg²⁺, glucose | None (D5LR is a separate product) | — |
| Calories | 9 kcal | Nutritionally negligible |
| Osmolarity | 273 mOsm/L (calculated) | Serum osmolality 275–295 mOsm/kg |
| pH | 6.5 (range 6.0–7.5) | 7.35–7.45 |
| Tonicity | Near-isotonic, slightly hypotonic | Large volumes can lower Na⁺ slightly |
- Chloride load: 109 mEq/L against 154 mEq/L in 0.9% saline. Large volumes cause far less hyperchloremic metabolic acidosis.
- Free water: Na⁺ of 130 mEq/L makes it slightly hypotonic. That is why 0.9% saline is preferred when brain swelling or hyponatremia is the concern.
- Where it goes: it spreads across the whole extracellular space. Once it equilibrates, only about one-quarter of a bolus (the plasma share of extracellular fluid) stays intravascular.
- Products: the US label values above are from Baxter. Other makers, and Hartmann's solution (compound sodium lactate) used outside the US, differ slightly. Check the bag.
Dosing & Administration
Doses vary by protocol; follow local protocols and medical direction.
Available Forms
- Lactated Ringer's Injection, USP: single-dose flexible bags of 250, 500 and 1,000 mL. The 1,000 mL bag is the size EMS and transport usually carry.
- Dextrose 5% in lactated Ringer's (D5LR): a separate product. Use it for maintenance when glucose is needed.
- Look-alikes: Lactated Ringer's Irrigation (never for IV use), D5LR and potassium chloride in D5LR. Read the label before you spike the bag.
Adult Dosing
| Indication | Dose & Route | Repeat / Max | Notes |
|---|---|---|---|
| Sepsis-induced hypoperfusion or septic shock | ≥30 mL/kg IV within the first 3 hr, given as boluses with reassessment after each | No fixed max: stop for overload or no response; then liberal or restrictive strategy per patient | Conditional recommendation (low certainty): individualize the volume, using smaller aliquots with frequent reassessment in heart failure, end-stage kidney disease or other overload-prone patients. Dosing weight: actual body weight, or adjusted or ideal body weight if BMI >30. Start norepinephrine if hypotension persists. TBI: use 0.9% saline |
| Hypovolemia or dehydration | Bolus volume per protocol (IV/IO), repeated after reassessment | No fixed max: titrate to perfusion and stop at signs of overload | Smaller boluses in heart failure, end-stage kidney disease or older adults |
| Hemorrhagic shock (bridge to blood) | Small IV/IO boluses only until blood is available, to permissive blood-pressure targets per protocol (not with suspected TBI) | Limit total crystalloid per protocol and switch to blood products early | No permissive hypotension if TBI is suspected: avoid any hypotension and keep adult SBP ≥110 mmHg (Brain Trauma Foundation prehospital 3rd edition), using 0.9% saline and blood. Crystalloid dilutes clotting factors and worsens acidosis and hypothermia. Give tranexamic acid per protocol |
| Thermal burns ≥20% TBSA | 2 mL/kg/%TBSA IV over the first 24 hr from the time of injury, half in the first 8 hr. Rule of 10s, if your protocol uses it (adults ≥40 kg): %TBSA rounded to the nearest 10 × 10 = starting mL/hr for 40–80 kg; add 100 mL/hr for each 10 kg above 80 kg. In most adults this falls between the 2 and 4 mL/kg/%TBSA estimates, but in heavy patients with smaller burns it can exceed 4 mL/kg, so check it against 2 mL/kg/%TBSA; titrate hourly to urine output | No fixed max: titrate hourly to urine output 0.5 mL/kg/hr (about 30–50 mL/hr) | The ABA 2024 guideline sets the 2 mL/kg/%TBSA starting dose; the 8-hour split, Rule of 10s and urine-output targets follow ABLS and burn-center protocol. Partial- and full-thickness burns only. Electrical injury or myoglobinuria: higher fluid needs and urine-output targets; follow ABLS and burn-center or medical-control direction. Consider albumin if volumes keep climbing. The classic Parkland 4 mL/kg/%TBSA is the upper estimate |
| DKA or hyperosmolar hyperglycemic state | 500–1,000 mL/hr IV for the first 2–4 hr (no renal or cardiac compromise), then per protocol | Rate after 2–4 hr per protocol; add dextrose when glucose <250 mg/dL | Check K⁺ before insulin: if K⁺ <3.5 mEq/L, hold insulin and replace potassium first; the 4 mEq/L in LR does not replace potassium. Consider smaller boluses (e.g., 250 mL) in older adults or with heart or kidney failure |
| Acute pancreatitis | 10 mL/kg IV bolus if hypovolemic (none if normovolemic), then 1.5 mL/kg/hr | Reassess clinical status often (the trial protocol adjusted fluids at 12, 24, 48 and 72 hr); avoid aggressive 20 mL/kg + 3 mL/kg/hr regimens | Aggressive rates caused more fluid overload without better outcomes in the WATERFALL trial |
| Maintenance (adult) | Rate per prescriber and local protocol, based on weight, ongoing losses and all other intake | No fixed max: review fluid balance and electrolytes daily | No glucose: use D5LR or add dextrose per order; check electrolytes at least daily |
Pediatric Dosing
| Indication | Dose (per kg) & Route | Max Single / Max Total | Notes |
|---|---|---|---|
| Septic shock (intensive care available) | 10–20 mL/kg IV/IO bolus, reassess after each | Up to 40–60 mL/kg in the first hr (SSC Children 2026, conditional); stop if shock resolves or overload appears (crackles, hepatomegaly) | Balanced crystalloid is the default for children with septic shock (Surviving Sepsis Campaign Children 2026, conditional). PRoMPT BOLUS (NEJM 2026, 9,041 children, 47 emergency departments) found no kidney-outcome difference: major adverse kidney event at 30 days 3.4% with balanced fluid vs 3.0% with 0.9% saline (risk ratio 1.10, 95% CI 0.88 to 1.40); hyperchloremia 31.4% vs 49.0%. Use 0.9% saline when raised ICP (for example CNS infection) is a concern. 2025 AHA Part 8 (COR 2a) states that either isotonic crystalloid or colloid, and either balanced or unbalanced crystalloid, can be effective; 10- or 20-mL/kg aliquots with frequent reassessment are reasonable |
| Septic shock (no intensive care) | Hypotension: 10–20 mL/kg IV/IO bolus. No hypotension: no bolus; maintenance fluid only | Up to 40 mL/kg in the first hr | SSC recommends against boluses without hypotension in this setting (strong recommendation, high certainty) |
| Hypovolemic shock or dehydration | 10–20 mL/kg IV/IO bolus, reassess after each | Adult cap 1,000 mL per bolus; stop at signs of overload | Use warmed fluid in infants to prevent hypothermia. See pediatric shock |
| Hemorrhagic shock | Crystalloid bolus per protocol only until blood is available, then blood products | Limit crystalloid; blood product volume per protocol | Avoid repeated crystalloid boluses while bleeding continues. 2025 AHA Part 8 (COR 2a, LOE C-EO): after hypotensive hemorrhagic shock from trauma, blood products when available are reasonable instead of crystalloid for ongoing volume resuscitation |
| DKA | 10–20 mL/kg IV over 20–30 min. Hypotension or shock: give the bolus within 10–15 min and repeat 10 mL/kg boluses with pediatric critical care input. Then deficit replacement per protocol | Max 1,000 mL per bolus; up to 40 mL/kg in shock; rate and total volume per institutional DKA protocol | 0.9% saline is the traditional first fluid; Canadian Paediatric Society guidance accepts a balanced crystalloid such as LR as a safe alternative. Protocols differ, so follow local policy |
| Burns >15% TBSA (some protocols ≥10%) | Burn-center or ABLS formula per protocol (threshold also per protocol), IV over 24 hr from the time of injury, plus dextrose-containing maintenance fluid | No fixed max: titrate to urine output per burn-center protocol, commonly 1 mL/kg/hr (<30 kg) or 0.5 mL/kg/hr (≥30 kg) | Do not use the adult Rule of 10s in children. Check glucose; infants need a dextrose source |
| Neonates (28 days or younger) | Contraindicated if receiving ceftriaxone. Otherwise 10–20 mL/kg 0.9% saline or blood for volume expansion when hypovolemia is suspected and the newborn stays bradycardic (under 60/min) despite ventilation, compressions and epinephrine (2025 AHA Part 5, COR 2b) | No maximum stated in 2025 AHA Part 5 | Immature kidneys: monitor electrolytes closely. 2025 AHA Part 5: normal saline is the crystalloid of choice when neonatal blood loss is suspected |
Pediatric doses run on weight. The math lives on weight-based dosing.
Preparation & Administration
- Line: peripheral IV or IO. Use the largest practical catheter for rapid boluses.
- Air embolism: use a non-vented set (or close the vent) on a dedicated line with no connections. Never connect bags in series. The label does not recommend pressure infusion to increase flow. If a pressure bag is needed (e.g., trauma), remove all air from the bag first. Avoid pressure above 300 mmHg, because it distorts the container. Stop any pump before the bag empties.
- Blood products: never through the same set as citrated blood. Prime transfusion sets with 0.9% saline.
- Ceftriaxone: never in the same line. In patients older than 28 days, give it sequentially, with a thorough flush between.
- Additives: some are incompatible. Mix thoroughly, inspect for precipitate, and do not store admixed bags.
- Pump: put maintenance and burn infusions on a pump with a set rate and volume limit.
Contraindications & Precautions
Contraindications
- Neonates 28 days or younger receiving ceftriaxone, even through separate lines (fatal ceftriaxone-calcium precipitates)
- Known hypersensitivity to any component
- Severe TBI or raised ICP, including sepsis with TBI (relative: use 0.9% saline)
Precautions
- Hyperkalemia risk: severe renal impairment, acute dehydration, extensive tissue injury (crush) or burns, heart failure, or drugs that raise K⁺. The label says avoid it. If use cannot be avoided, monitor K⁺ closely.
- Hyponatremia risk: young children, older adults, diuretics, heart or pulmonary failure, SIADH and postoperative patients. The label says avoid it in patients with or at risk for hyponatremia. If use cannot be avoided, monitor Na⁺ closely. When you correct hyponatremia, avoid overly rapid correction. That is the osmotic demyelination risk.
- Hypercalcemia: calcium kidney stones, thiazide diuretics or vitamin D therapy
- Fluid overload: heart failure, severe renal impairment, cirrhosis
- Metabolic alkalosis: lactate becomes bicarbonate, and that can worsen the alkalosis.
- Severe hepatic impairment or shock liver: lactate may not be cleared, and the anion-gap acidosis can get worse. The label says avoid it. If use cannot be avoided, monitor bicarbonate closely.
- Not a treatment for lactic acidosis: the lactate buffer does not correct it. LR is still appropriate for resuscitation in sepsis with a raised lactate.
- Digoxin: the added calcium may increase toxicity. Consider a lower volume or rate.
Hold / Reassess If
- New crackles, falling SpO₂, rising work of breathing or rising oxygen need: stop, reassess volume
- No rise in blood pressure, perfusion or urine output after a bolus: reassess before more fluid; consider vasopressor or blood
- Na⁺ <135 mEq/L and falling, or new headache, vomiting or confusion: stop, check Na⁺
- K⁺ above the reference range with renal impairment: switch fluid per prescriber
- Burn urine output well above target: reduce the rate to avoid fluid creep
Pressure Bags and Air: Air embolism with pressurized fluid has caused stroke and death. Pull all the air out of the bag before you pressurize it. Use a non-vented set on a dedicated line, and never connect bags in series.
Adverse Effects & Toxicity
Common
- Infusion-site reactions: phlebitis, extravasation, swelling, pain or burning
- Hypersensitivity symptoms: pruritus, urticaria, rash, cough, dyspnea
- Peripheral and tissue edema after large volumes
- Small rise in measured serum lactate. In severe metabolic acidosis, don't judge the patient by lactate alone.
Serious / Life-Threatening
| Effect | Recognition | Management |
|---|---|---|
| Fluid overload and pulmonary edema | Crackles, falling SpO₂, edema, raised jugular venous pressure; burns: abdominal compartment syndrome | Stop; sit up; oxygen, CPAP or ventilation; furosemide if not hypovolemic |
| Hyponatremic encephalopathy | Headache, nausea, vomiting, lethargy, seizures | Stop; STAT Na⁺; severe symptoms: 3% saline per protocol; avoid overly rapid correction (osmotic demyelination risk); monitor Na⁺, fluid status and neurologic status |
| Hyperkalemia | Peaked T waves, weakness; rising K⁺ in renal failure | Stop; ECG; IV calcium and shift therapy per protocol |
| Anaphylaxis or angioedema | Urticaria, bronchospasm, hypotension, laryngeal edema | Stop immediately; IM epinephrine per protocol |
| Air embolism | Sudden dyspnea, hypotension, stroke or arrest during a pressurized infusion | Stop and clamp; high-flow oxygen; resuscitate |
Overdose & Toxicity Management
- Signs: fluid overload with pulmonary or peripheral edema; hyperkalemia and hypernatremia in severe renal impairment; metabolic alkalosis with or without hypokalemia; hypercalcemia
- Management: stop the infusion. Correct electrolytes. Monitor fluid balance, electrolytes and acid-base status.
- Antidote: none
Monitoring
| Parameter | When / How Often | Target / Act If |
|---|---|---|
| Clinical: perfusion | Before and after every bolus | Heart rate, blood pressure (MAP target about 65 mmHg in adult septic shock; 60–65 mmHg is reasonable at age 65 or older), capillary refill, mental status; no response: reassess before more fluid |
| Clinical: lungs and SpO₂ | Every assessment, especially during boluses | Crackles, falling SpO₂ or rising work of breathing: stop, reassess volume |
| Clinical: urine output | Hourly in shock, burns and DKA (urinary catheter) | Adults 0.5 mL/kg/hr; children <30 kg 1 mL/kg/hr in burns (per burn-center protocol); myoglobinuria (rhabdomyolysis, crush or electrical injury): higher target per protocol; low: reassess; burns well above target: reduce rate |
| Clinical: fluid balance and weight | Running total during resuscitation; daily after | Large positive balance once stable: de-resuscitate (stop maintenance, consider diuretic) |
| Laboratory: lactate | Baseline and serial in sepsis | Use the trend with clinical signs; do not keep giving fluid only to normalize lactate (lactate) |
| Laboratory: Na⁺, K⁺, Cl⁻, HCO₃⁻ | Baseline; every 2–4 hr in DKA or large-volume resuscitation; daily on maintenance | |
| Laboratory: creatinine, glucose, calcium | Baseline and daily; glucose hourly on insulin infusions | Rising creatinine with low urine output: reassess volume and potassium load (creatinine, glucose, calcium) |
| Infusion Safety: bag, line and rate | Start, bag change, handoff | Right fluid (LR injection, not irrigation or D5LR unless ordered); no ceftriaxone or citrated blood in the line; pump rate matches order |
Interactions & Compatibility
Clinically Significant Interactions
| Drug / Class | Effect | What To Do |
|---|---|---|
| Ceftriaxone | Ceftriaxone-calcium precipitate; fatal in neonates even with separate lines | Neonates: never together. Older than 28 days: separate line, or flush thoroughly between |
| Drugs that raise K⁺: potassium-sparing diuretics, ACE inhibitors, angiotensin receptor blockers, calcineurin inhibitors | Higher risk of hyperkalemia | Avoid if possible; otherwise monitor K⁺ |
| Thiazide diuretics, vitamin D | Hypercalcemia | Avoid if possible; otherwise monitor calcium |
| Digoxin | Added calcium may increase digoxin toxicity and arrhythmias | Consider lower volume or rate; monitor ECG |
| Lithium | Sodium increases lithium clearance; levels fall | Avoid if possible; check lithium levels more often |
| Diuretics, vasopressin analogs, some antiepileptic, psychotropic and cytotoxic drugs | Higher risk of hyponatremia | Avoid if possible; otherwise monitor Na⁺ |
| Corticosteroids, corticotropin | Sodium and fluid retention: hypernatremia and volume overload | Avoid if possible; otherwise monitor electrolytes, fluid balance and acid-base status |
| Drugs with pH-dependent renal elimination | Lactate alkalinizes: renal clearance of alkaline drugs may fall and of acidic drugs may rise | Monitor drug levels or effect |
IV Compatibility
- Blood products: not through the same administration set as citrated blood. Calcium can clot it. Transfuse through a 0.9% saline-primed set.
- Ceftriaxone: incompatible in the same line (see table).
- Other additives: some precipitate with calcium, and some are pH-sensitive. Check each drug's label and consult pharmacy.
- Verify with your institution's compatibility resource.
Special Populations
- Pediatrics: safety and effectiveness are established at all ages. Kids run a higher risk of hyponatremia, and of fluid overload from repeated boluses. Reassess after every bolus. See the Pediatric Dosing table.
- Neonates: contraindicated with ceftriaxone. Immature kidneys and liver handle electrolytes and lactate less well. Monitor electrolytes closely.
- Pregnancy: it has been used for decades in labor and delivery. Exposure is not expected to cause birth defects, miscarriage or adverse maternal or fetal outcomes. Give it when indicated. Pre-eclampsia raises the risk of pulmonary edema, so limit volume and reassess.
- Lactation: there are no data on transfer into milk. It is not expected to harm a breastfed infant.
- Older Adults: they carry a higher risk of electrolyte imbalance and overload. Consider starting at the low end, giving smaller boluses and checking renal function.
- Renal Impairment: the label advises avoiding LR in severe renal impairment because of hyperkalemia and overload. If you use it, monitor K⁺ and fluid balance.
- Hepatic Impairment: severe impairment may block lactate metabolism. LR may then fail to alkalinize, and anion-gap acidosis can worsen. The label advises avoiding LR in severe hepatic impairment. If it cannot be avoided, monitor lactate, bicarbonate and acid-base status.
- Obesity / Dosing Weight: for sepsis volumes, adjusted or ideal body weight may be used when BMI >30.
- Traumatic Brain Injury: use 0.9% saline. LR is slightly hypotonic. In an individual-patient meta-analysis of ICU trials, balanced fluid was associated with higher mortality in patients with TBI.
Field & Transport Considerations
- Scope: IV or IO fluid is typically an AEMT, Paramedic, RN and critical-care transport (Paramedic/RN/CCT) skill. Scope varies by state and agency protocol.
- Storage & Stability: keep it at room temperature (25°C (77°F)) in the overwrap. A brief exposure up to 40°C (104°F) does not harm the product. Avoid excessive vehicle heat and freezing. Once it is out of the overwrap, use it right away.
- Temperature: warm the fluid for trauma, burns, infants and large volumes, per protocol, to prevent hypothermia.
- Pressure Infusion: the label does not recommend pressure infusion to increase flow. If a pressure bag is needed (e.g., trauma), remove all air from the bag first. Use a non-vented set (or close the vent) on a dedicated line with no connections. Never connect bags in series. Avoid pressure above 300 mmHg, which distorts the container. Stop any pump before the bag empties.
- Burns en Route: start the formula clock at the time of injury, not at arrival. Record the total volume given before arrival, so the burn center can recalculate. Electrical injury or myoglobinuria brings higher fluid needs and urine-output targets. Follow ABLS and burn-center or medical-control direction.
- Handoff Essentials: indication, total volume and times of each bolus, current rate, response (blood pressure, perfusion, urine output), lung findings, and any ceftriaxone or blood given through the line.
Clinical Pearls
Burn Fluid Creep: Starting at Parkland 4 mL/kg/%TBSA and rarely turning it down is how you over-resuscitate. Compartment syndromes and airway edema follow. Start at 2 mL/kg/%TBSA. Let hourly urine output set the rate.
Exam Discriminator, LR or Saline in Head Injury: Severe TBI or raised ICP? Go with 0.9% saline. LR runs slightly hypotonic. The house position is saline whenever sepsis and TBI coexist.
LR Does Not Cause Lactic Acidosis: The liver turns that lactate into bicarbonate. The rise in measured lactate is small. Read the trend with the clinical picture. That matters most in severe acidosis or liver failure.
LR and Potassium: In crush injury, use 0.9% saline, not lactated Ringer's. NASEMSO 2022 gives 1,000 mL normal saline before release, and it says avoid LR because LR contains potassium. The LR label also says avoid it when hyperkalemia is a risk.
What the Big Trials Show: A meta-analysis of six ICU trials (about 34,500 adults, individual patient data) found a probable small mortality benefit with balanced fluid (16.8% vs 17.3%). Here's the catch: in TBI, balanced fluid carried higher mortality (19.1% vs 14.7%). The house default is balanced fluid. Switch to 0.9% saline in TBI.
Crystalloids Compared (Na⁺ / Cl⁻ mEq/L; osmolarity):
- Lactated Ringer's: 130 / 109; 273 mOsm/L; lactate buffer; contains calcium
- 0.9% saline: 154 / 154; 308 mOsm/L; no buffer
- Plasma-Lyte A: 140 / 98; 294 mOsm/L; acetate and gluconate buffers; no calcium
Pharmacology
Mechanism of Action
- Supplies water and electrolytes close to plasma concentrations. That expands extracellular (and briefly intravascular) volume, which restores preload and perfusion.
- Low chloride (109 mEq/L) means less hyperchloremic metabolic acidosis than 0.9% saline.
- The liver takes up lactate with hydrogen ions and converts it to bicarbonate. The result is a mild alkalinizing effect.
- Calcium (2.7 mEq/L) is physiologic. It also clots citrated blood and precipitates ceftriaxone in the line.
Pharmacokinetics
| Route | Onset | Peak | Duration |
|---|---|---|---|
| IV or IO infusion | Immediate | End of the bolus | Volume-based: the plasma volume gain fades as fluid moves into the interstitium |
- Half-life: there is no meaningful drug half-life. The effect follows volume, rate and capillary leak.
- Metabolism: the liver mainly metabolizes lactate (the kidney does too) to carbon dioxide and water, generating bicarbonate.
- Elimination: the kidneys mainly excrete the sodium, chloride and potassium.
Names & Classification
- Generic Name
- Lactated Ringer's Injection, USP (sodium chloride, sodium lactate, potassium chloride and calcium chloride); Ringer's lactate, LR
- Brand Names
- Generic; US makers include Baxter, B. Braun and Fresenius Kabi. Similar products abroad: Hartmann's solution (compound sodium lactate)
- Pharmacologic Class
- Balanced crystalloid (electrolyte solution with lactate buffer)
- Therapeutic Class
- IV fluid; volume and electrolyte replacement; alkalinizing agent
- Controlled Substance
- Not controlled
- ISMP High-Alert
- No
- Look-Alike / Sound-Alike
- None commonly reported as a named pair; in practice LR injection, LR irrigation and D5LR bags look alike
References
- Baxter Healthcare Corporation. (2025). Lactated Ringer's Injection, USP, in VIAFLEX plastic container: Prescribing information. DailyMed, U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=dad7735c-709b-40ea-ab7a-15577e24a966
- Prescott, H. C., Antonelli, M., Alhazzani, W., et al. (2026). Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2026. Critical Care Medicine, 54(4), 725–812. https://doi.org/10.1097/CCM.0000000000007075
- Weiss, S. L., Peters, M. J., Oczkowski, S. J., et al. (2026). Surviving Sepsis Campaign international guidelines for the management of sepsis and septic shock in children 2026. Pediatric Critical Care Medicine, 27(4), 379–434. https://doi.org/10.1097/PCC.0000000000003927
- Cartotto, R., Johnson, L. S., Savetamal, A., et al. (2024). American Burn Association clinical practice guidelines on burn shock resuscitation. Journal of Burn Care & Research, 45(3), 565–589. https://doi.org/10.1093/jbcr/irad125
- Umpierrez, G. E., Davis, G. M., ElSayed, N. A., et al. (2024). Hyperglycemic crises in adults with diabetes: A consensus report. Diabetes Care, 47(8), 1257–1275. https://doi.org/10.2337/dci24-0032
- Gripp, K. E., Trottier, E. D., Thakore, S., Sniderman, J., & Lawrence, S. (2023). Current recommendations for management of paediatric diabetic ketoacidosis. Paediatrics & Child Health, 28(2), 128–132. https://doi.org/10.1093/pch/pxac119
- de-Madaria, E., Buxbaum, J. L., Maisonneuve, P., et al. (2022). Aggressive or moderate fluid resuscitation in acute pancreatitis (WATERFALL). New England Journal of Medicine, 387(11), 989–1000. https://doi.org/10.1056/NEJMoa2202884
- Zampieri, F. G., Cavalcanti, A. B., Di Tanna, G. L., et al. (2024). Balanced crystalloids versus saline for critically ill patients (BEST-Living): A systematic review and individual patient data meta-analysis. The Lancet Respiratory Medicine, 12(3), 237–246. https://doi.org/10.1016/S2213-2600(23)00417-4
- Balamuth, F., Weiss, S. L., Long, E., et al. (2026). Balanced fluid or 0.9% saline in children treated for septic shock (PRoMPT BOLUS). New England Journal of Medicine, 395(9), 870–881. https://doi.org/10.1056/NEJMoa2601969
- National Association of State EMS Officials. (2022). National Model EMS Clinical Guidelines, Version 3.0 (March 2022), Crush Injury/Crush Syndrome, p. 222. https://hhs.iowa.gov/media/198/download
- Hawryluk, G. W. J., Lulla, A., Bell, R., Jagoda, A., Mangat, H. S., Bobrow, B. J., & Ghajar, J. (2023). Guidelines for prehospital management of traumatic brain injury, 3rd edition: Executive summary (Brain Trauma Foundation). Neurosurgery, e159–e169. https://doi.org/10.1227/neu.0000000000002672
- American Heart Association. (2025). 2025 AHA Guidelines for CPR and ECC, Part 5: Neonatal Resuscitation, https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/neonatal-resuscitation; and Part 8: Pediatric Advanced Life Support, https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/pediatric-advanced-life-support
Medical Disclaimer
- For Educational Purposes Only: This content is intended for educational reference and should not be used for clinical decision-making.
- Not a Substitute for Professional Judgment: Always consult your local protocols, institutional guidelines, and supervising physicians.
- Verify Before Acting: Users are responsible for verifying information through authoritative sources before any clinical application.
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