Source of water and electrolytes. Regulation or maintenance of metabolic acidosis (except lactic acidosis).

Adults, the Elderly and Children:

The dosage depends on the age, weight, clinical and biological (acid-base balance) conditions of the patient, and concomitant therapy.

 

Recommended dosage:

The amount of Lactated Ringer’s Injection needed to restore normal blood volume is 3 to 5 times the volume of lost blood.

 

The recommended dosage is:

-    for adults : 500 ml to 3 Liters /24 h

-    for babies and children : 20 ml to 100 ml / kg / 24 h

 

Administration rate:

The infusion rate is usually 40 mL/kg/24 h in adults.

In pediatric patients the infusion rate is 5 ml/kg/h in average but the value varies with age: 6-8 mL/kg/h for infants, 4-6 mL/kg/h for toddlers, and 2-4 mL/kg/h for schoolchildren. In children with burns, the dose is on average 3.4 mL/kg/per cent burn at 24 h post-burn and 6.3 mL/kg/per cent burn at 48 h. In severely head-injured children the dose is on average 2850 mL/m².

Infusion rate and total volume can be higher in surgery or in case of need.

Note:

-    infants and toddlers: age ranges from about 28 days to 23 months (a toddler is an infant who can walk)

-    Children and Schoolchildren: age ranges from about 2 years to 11 years

 

Administration:

The administration is performed by intravenous route using sterile and non-pyrogenic equipment.

The solution is contra-indicated in patients presenting: - Extracellular hyperhydration or hypervolemia - Severe renal insufficiency (with oliguria/anuria) - Uncompensated cardiac failure - Hyperkalemia - Hypernatremia - Hypercalcaemia - Hyperchloremia - Metabolic alkalosis - Severe metabolic acidosis. - Lactic acidosis. - Severe hepatocellular insufficiency or impaired lactate metabolism - General oedema and ascitic cirrhosis - Concomitant digitalis therapy (see section 4.5 “Interactions with other medicinal products and other forms of interaction”)precipitation in the neonate's bloodstream).

High volume infusion must be used under specific monitoring in patients with cardiac or pulmonary failure.

The patient's clinical status and laboratory parameters (blood and urine electrolytes as well as acid-base balance) must be monitored during use of this solution. The plasma potassium level of the patient must be particularly closely monitored in patients at risk of hyperkalaemia.

Solutions containing sodium chloride should be carefully administered to patients with hypertension, heart failure, peripheral or pulmonary edema, impaired renal function, pre-eclampsia, aldosteronism, or other conditions associated with sodium retention (see also Section 4.5 - Interactions with other medicinal products and other forms of interaction).

Solutions containing potassium salts should be administered with caution to patients with cardiac disease or conditions predisposing to hyperkalemia such as renal or adrenocortical insufficiency, acute dehydration, or extensive tissue destruction as occurs with severe burns.

Although Lactated Ringer’s Injection has a potassium concentration similar to the concentration in plasma, it is insufficient to produce a useful effect in case of severe potassium insufficiency and therefore it should not be used for this purpose.

Calcium chloride is irritant, therefore care should be taken to prevent extravasation during intravenous injection and intramuscular injection must be avoided. Solutions containing calcium salts should be given cautiously to patients with impaired renal function, or disease associated with elevated vitamin D concentrations such as sarcoidosis. They should be avoided in patients with calcium renal calculi, or a history of renal calculi. In case of concomitant blood transfusion and because of the presence of calcium, Lactated Ringer’s Injection must not be administered via the same infusion system because of the risk of coagulation.

Infusion of Lactated Ringer’s solution may cause metabolic alkalosis because of the presence of lactate ions.

Lactated Ringer’s Injection may not produce its alkalinizing action in patients with liver insufficiency since lactate metabolism may be impaired

The solution containing lactate should be administered with particular care to neonates less than 3 months old.

During long term parenteral treatment, a convenient nutritive supply must be given to the patient.

Interaction related to the presence of sodium:

-    Corticoids/Steroids and carbenoxolone which are associated with the retention of sodium and water (with oedema and hypertension).

 

Interaction related to the presence of potassium:

-    Potassium-sparing diuretics (amiloride, spironolactone, triamterene, alone or in association).

-    Angiotensin converting enzyme inhibitors (ACEi) and, by extrapolation, angiotensin II receptor antagonists

-    Tacrolimus, cyclosporin

which increase concentration of potassium in the plasma and may lead to potentially fatal hyperkalemia notably in case of a renal failure increasing the hyperkalemic effect

 

Interaction related to the presence of calcium:

-    Digitalis glycosides (digitalis cardiotonic) whose effects are enhanced by the presence of calcium and may lead to serious or fatal cardiac arrhythmia.

-    Thiazide diuretics or vitamin D which can lead to hypercalcaemia when co-administered with calcium

-    Bisphosphonates, fluoride, some fluoroquinolones and tetracyclines which are less absorbed (lower availability) when administered with calcium.

 

Interaction related to the presence of lactate (which is metabolized into bicarbonate):

-    Acidic drugs such as salicylates, barbiturates and lithium whose renal clearance is increased because of the alkalinisation of urine by the bicarbonate resulting from lactate metabolism.

-    Alkaline drugs, notably sympathomimetics (e.g. ephedrine, pseudoephedrine) and stimulants (e.g. dexamphetamine sulphate, phenfluramine hydrochloride) whose half-life is prolonged (slowest elimination).

Lactated Ringer’s Injection can be used safely during pregnancy and lactation as long as the electrolyte- and fluid balance is controlled.

It is reminded that calcium crosses the placenta and is distributed into breast milk.

When a medication is added, the nature of the drug and its use during pregnancy and lactation have to be considered separately.

Not applicable.

During administration of Lactated Ringer’s Injection, the following undesirable effects have been reported as:

 

§ very common:

Allergic reactions or anaphylactic/anaphylactoid symptoms such as localized or generalized urticaria, skin rash & erythema and itching/pruritis; skin swelling, periobial facial and/or laryngeal edema (Quincke's edema).

Nasal congestion, coughing, sneezing, bronchospasm and/or difficulty breathing.

 

§ common:

Chest tightness, chest pain, with tachycardia or bradycardia.

Pruritus has been reported to occur in about 10% of patients receiving Lactated Ringer’s Injection.

Hyperhydration and heart failure are very common in patient with cardiac disorder or pulmonary oedema

Electrolytes disturbances have been very commonly reported too.

Lactate infusions commonly induce feeling of anxiety, and few cases of panic attack have been reported

Seizure may be precipitated by the alkalosis induced by lactate but this is uncommon.

Adverse reactions may be associated with the technique of administration including febrile response, infection at the site of injection, local pain or reaction, vein irritation, venous thrombosis or phlebitis extending from the site of injection, extravasation, and hypervolemia.

Adverse reactions may be associated to the medications added to the solution; the nature of the additive will determine the likelihood of any other undesirable effects.

In case of undesirable effect(s), the infusion must be discontinued

 

To report any side effect(s):

 

Saudi Arabia, Saudi Food & Drug Authority: National Pharmacovigilance Center To contact Executive Administration for Pharmacovigilance & Crisis Management. Tel: +966-11-203-8222 ext 2340-2317-2356 Hotline: 19999 FAX: +966112057662 E-MAIL: npc.drug@sfda.gov.sa WEBSITE: www.sfda.gov.sa/npc

Overuse or too fast administration may lead to water and sodium overload with a risk of oedema, particularly when there is a defective renal sodium excretion. In this case extra renal dialysis may be necessary.

Excessive administration of potassium may lead to the development of hyperkalemia, especially in patients with renal impairment. Symptoms include paresthesia of the extremities, muscle weakness, paralysis, cardiac arrhythmias, heart block, cardiac arrest, and mental confusion.

Excessive administration of calcium salts may lead to hypercalcemia. Symptoms of hypercalcemia may include anorexia, nausea, vomiting, constipation, abdominal pain, muscle weakness, mental disturbances, polydipsia, polyuria, nephrocalcinosis, renal calculi, and, in severe cases, cardiac arrhythmias and coma. Too rapid intravenous injection of calcium salts may also lead to many of the symptoms of hypercalcemia as well as to chalky taste, hot flushes, and peripheral vasodilatation. Mild asymptomatic hypercalcemia will usually resolve on stopping administration of calcium and other contributory drugs such as vitamin D. If hypercalcemia is severe, urgent treatment (such as loop diuretics, hemodialysis, calcitonin, bisphosphonates, trisodium edetate) is required.

Excessive administration of sodium lactate may lead to hypokalemia and metabolic alkalosis, especially in patients with impaired renal function. Symptoms may include mood changes, tiredness, shortness of breath, muscle weakness, and irregular heartbeat. Muscle hypertonicity, twitching, and tetany may develop especially in hypocalcemic patients. Treatment of metabolic alkalosis associated with bicarbonate overdose consists mainly of appropriate correction of fluid and electrolyte balance. Replacement of calcium, chloride, and potassium may be of particular importance.

When overdose is related to medications added to the solution infused, the signs and symptoms of over infusion will be related to the nature of the additive being used. In the event of accidental over infusion, treatment should be discontinued and the patient should be observed for the appropriate signs and symptoms related to the drug administered. The relevant symptomatic and supportive measures should be provided as necessary.

 

Pharmacotherapeutic group (ATC code): B05BB01 “Electrolytes”

Lactated Ringer’s Injection is an isotonic solution of electrolytes. The constituents of Lactated Ringer’s Injection and their concentrations are designed to match those of plasma.

The pharmacological properties of the Lactated Ringer’s Injection are those of its components (sodium, potassium, calcium, chloride and lactate).

The main effect of Lactated Ringer’s Injection is the expansion of the extracellular compartment including both the interstitial fluid and the intravascular fluid.

The lactate is metabolised into bicarbonate, mainly in the liver, and produces an alkalinising effect on the plasma

In healthy volunteers receiving Lactated Ringer’s Injection, central venous pressure changes were associated with a secretion of atrial natriuretic peptide

In healthy volunteers, Lactated Ringer’s Injection decreased serum osmolality, increased blood pH, and the time until first urination was shorter than that with normal saline.

There is no significant changes in glucagon, norepinephrine, epinephrine, blood glucose and insulin levels in aortic surgery patients receiving Lactated Ringer’s Injection.

When medication is added to Lactated Ringer’s Injection, the overall pharmacodynamics of the solution will depend on the nature of the drug used.

 

The pharmacokinetic properties of the Lactated Ringer’s Injection are those of the ions its composition includes (sodium, potassium, calcium and chloride).

Infusion of Lactated Ringer’s Injection in normal hemodynamically stable adults does not increase circulating lactate concentrations.

The pharmacokinetics of D-lactate and L-lactate are similar.

The lactate in Lactated Ringer’s Injection is metabolized by both oxidation and gluconeogenesis, predominantly in the liver, and bicarbonate is generated by both processes over 1-2 h.

When medication is added to Lactated Ringer’s Injection, the overall pharmacokinetics of the solution will depend on the nature of the drug used.

Preclinical safety data of Lactated Ringer’s Injection in animals are not relevant since its constituents are physiological components in animal and human plasma.

Toxic effects are not to be expected under the condition of clinical application.

The safety of potential additives should be considered separately

The other ingredient in each 100 ml is:

 

Water for Injection

Q.S.

As with all parenteral solutions, before adding medications, compatibility of these additives with the solution in bottle must be assessed.

It is the responsibility of the physician to judge the incompatibility of an additive medication with the Lactated Ringer’s Injection by checking for eventual color change and/or eventual precipitate, insoluble complexes or crystals apparition. The Instructions for Use of the medication to be added must be consulted.

Before adding a drug, verify it is soluble and stable in water at the pH of Lactated Ringer’s Injection (pH 6.0 to 7.5).

When a compatible medication is added to the Lactated Ringer’s Injection, the solution must be administered immediately.

As a guidance the following medications are incompatible with the Lactated Ringer’s Injection (non-exhaustive listing):

§ Medications incompatible with Lactated Ringer’s Injection

-    Aminocaproic acid

-    Amphotericin B

-    Metaraminol tartrate

-    Cefamandole

-    Cortisone acetate

-    Diethylstilbestrol

-    Etamivan

-    Ethyl alcohol

-    Phosphate and carbonate solutions

-    Oxytetracycline

-    Thiopental sodium

-    Versenate disodium

 

§ Medications with partial incompatibility with Lactated Ringer’s Injection:

-    Tetracycline stable for 12 hours

-    Ampicillin sodium

concentration of 2%-3% stable for 4 hours

concentration >3% must be given within 1 hour

-    Minocycline stable for 12 hours

-    Doxycycline stable for 6 hours

Those additives known to be incompatible should not be used.

Unopened: 5 years from the manufacturing date. The expiry date refers to the last day of the month. In-use shelf life: Additives From a microbiological point of view, the diluted product must be used immediately unless dilution has taken place in controlled and validated aseptic conditions. If not used immediately, in-use storage times and conditions are the responsibility of the user.

§ Keep in a safe place, out of the reach and sight of children.

§ Store below 25º C.

Bottle size: 500 ml × 10 Bottles

Sterile, pyrogen free.

 

Polyethylene granules:

White colored, round to oblong shaped granules, which are used for the production of containers for intravenous solutions.

Use only if the solution is clear, without visible particles and if the container is undamaged. Administer immediately following the insertion of infusion set.

Do not remove unit from overwrap until ready for use.

Do not use plastic containers in series connections. Such use could result in air embolism due to residual air being drawn from the primary container before the administration of the fluid from the secondary container is completed.

The solution should be administered with sterile equipment using an aseptic technique. The equipment should be primed with the solution in order to prevent air entering the system.

Additives may be introduced before infusion or during infusion through the injection site.

When additive is used, verify isotonicity prior to parenteral administration. Thorough and careful aseptic mixing of any additive is mandatory. Solutions containing additives should be used immediately and not stored.

Adding other medication or using an incorrect administration technique might cause the appearance of fever reactions due to the possible introduction of pyrogens. In case of adverse reaction, infusion must be stopped immediately.

Discard after single use.

Discard any unused portion.

Do not reconnect partially used bottles.

 

1.   Opening

a.    If leaks are found, discard solution, as sterility may be impaired.

b.   Check the solution for limpidity and absence of foreign matters. If solution is not clear or contains foreign matters, discard the solution.

 

2.   Preparation for administration

Use sterile material for preparation and administration.

a.    Suspend container from eyelet support.

b.   Remove plastic protector from outlet port at bottom of container:

c.    Use an aseptic method to set up the infusion.

d.   Attach administration set. Refer to complete directions accompanying set for connection, priming of the set and administration of the solution.

 

3.   Techniques for injection of additive medications

Warning: Additives may be incompatible.

To add medication before administration

a.    Disinfect medication site.

b.   Using syringe with 19 to 22 gauge needle, puncture and inject.

c.    Mix solution and medication thoroughly. For high-density medication such as potassium chloride, tap the ports gently while ports are upright and mix.

Caution: Do not store bottles containing added medications.

 

To add medication during administration

a.    Close clamp on the set.

b.   Disinfect medication site.

c.    Using syringe with 19 to 22 gauge needle, puncture and inject.

d.   Remove container from IV pole and/or turn to an upright position.

e.    Evacuate both ports by tapping gently while the container is in an upright position.

f.    Mix solution and medication thoroughly.

g.   Return container to in use position, re-open the clamp and continue administration.