Maintenance Fluid Therapy with Lactated Ringer's Solution

Primary Recommendations

The World Journal of Emergency Surgery guidelines recommend using balanced crystalloids like lactated Ringer's (LR) solution for maintenance fluid therapy, as they result in improved patient outcomes and reduced morbidity and mortality compared to normal saline, based on the SMART trial (15,802 patients) and SALT trial (974 patients) 1
Patients receiving balanced crystalloids like LR had lower incidence of major adverse kidney events (14.3% vs 15.4%), reduced 30-day in-hospital mortality, lower rates of renal replacement therapy, and decreased vasopressor requirements 1

The European trauma guidelines state that hypotonic solutions like Ringer's lactate should be avoided in patients with severe head trauma (GCS <8), and instead recommend using 0.9% saline as the isotonic crystalloid of choice (308 mOsm/L) 2
For patients with severe traumatic brain injury, maintain mean arterial pressure ≥80 mmHg 2

Lactated Ringer's solution prevents hyperchloremic metabolic acidosis that occurs with prolonged normal saline administration, as seen in kidney transplant recipients where 31% of patients receiving normal saline required treatment for metabolic acidosis versus 0% receiving LR 1
The balanced electrolyte composition of LR protects kidney function during extended use, causing decreased kidney perfusion, reduced urine output, increased extravascular fluid accumulation, and higher risk of acute kidney injury with normal saline 1

For burns management, lactated Ringer's solution is recommended as first-line balanced fluid resuscitation solution despite being slightly hypotonic, due to its electrolyte composition closely matching plasma, and should be continued for maintenance after initial resuscitation 4
For emergency laparotomy patients, target postoperative fluid balance of 0-2 L using balanced crystalloids like LR, and avoid normal saline especially in higher-risk patients with existing acidosis or hyperchloremia 1
For severe dehydration with shock, use isotonic crystalloids like LR until pulse, perfusion, and mental status normalize, and continue LR for maintenance fluid replacement of ongoing losses 5

Track fluid balance carefully throughout treatment, monitor electrolytes, particularly in patients with renal dysfunction, and assess for signs of volume overload (peripheral edema, pulmonary congestion) 1
In patients with severe traumatic brain injury, use normal saline instead of LR and monitor intracranial pressure 2, 3
Avoid using hydroxyethyl starch (HES) solutions due to increased risk of kidney failure and mortality without demonstrated benefit 1