Why might Lactated Ringer’s (LR) solution be preferred over normal saline (NS) for fluid resuscitation in acute pancreatitis?

Although the data is limited, fluid resuscitation with lactated Ringer’s (LR) solution in acute pancreatitis has been associated with lower risk of persistent systemic inflammatory response syndrome (SIRS) compared to normal saline (NS),  with an additional trend toward lower mortality.1-3

A 2018 meta-analysis of 3 randomized-controlled trials (RCTs) and 2 retrospective studies involving 428 patients found a significantly lower odds of developing SIRS at 24 hours (OR 0.38, CI 0.15-0.98).   Mortality was also lower in the LR group (OR 0.61, 95% CI 0.28-1.29), though it did not reach statistical significance. 1

A small 2011 RCT was the first to suggest the “protective” effect of LR in acute pancreatitis, reporting significant reduction in the prevalence of SIRS after 24 hours when compared to NS (84% vs 0%);  patients on LR also had a significantly lower C-reactive protein (CRP) (104 mg/L vs 51.4 mg/L) at 24 hours. 2   Significantly lower CRP levels were also reported at 48 and 72 hours when LR was compared to NS in another RCT in acute pancreatitis.3

As for potential mechanisms for the observed beneficial effects of LR on the pancreatic tissue in acute pancreatitis, hyperchloremic metabolic acidosis (with its attendant low extracellular pH) often seen in large volume NS resuscitation was initially thought to contribute to pancreatic injury.2  A more plausible explanation, however, may relate to the direct anti-inflammatory effect of lactate itself.  Of interest, lactate has been shown to inhibit macrophage induction invitro 4  and suppress innate immunity in experimental models of pancreatitis. 3 Who would have guessed!

Bonus Pearl: Did you know that Ringer’s solution gets its name from Sydney Ringer, a 19th century physician who demonstrated the importance of salts of sodium, potassium, calcium and chloride in precise proportions for cellular function?  LR solution was actually concocted in the 1930s by a St. Louis pediatrician, Alexis Hartmann, and was also known as the “Hartmann’s solution”. 4

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References

  1. Iqbal U, Anwar H, Scribani M. Ringer’s lactate versus normal saline in acute pancreatitis: A systematic review and meta-analysis. J Dig Dis 208;19:335-341. https://onlinelibrary.wiley.com/doi/epdf/10.1111/1751-2980.12606
  2. Wu BU, Hwang JQ, Gardner TH, et al. Clin Gastroenterol Hepatol 2011;9:710-17. https://www.cghjournal.org/article/S1542-3565(11)00454-X/abstract
  3. de-Madaria E, Herrera-Marante I, Gonzalez-Camacho V, et al. Fluid resuscitation with lactated Ringer’s solution vs normal saline in acute pancreatitis: A triple-blind, randomized, controlled trial. UEG J 2017;6:63-72. file:///C:/Users/manifa/OneDrive%20-%20Mercy%20Online/pancreatitis%20LR2spain.pdf
  4. Lee JA. Sydney Ringer (1834-1910) and Alexis Hartmann (1898-1964). Anaesthesia 1981;36:1115-21. https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2044.1981.tb08698.x

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis or its affiliate healthcare centers. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

 

Why might Lactated Ringer’s (LR) solution be preferred over normal saline (NS) for fluid resuscitation in acute pancreatitis?