4.1. Therapeutic indications

Ringer Lactate solution is indicated for:

- Restoration of extracellular fluid and electrolyte balances or replacement of extracellular fluid loss where isotonic concentrations of electrolytes are sufficient.

- Short term volume replacement (alone or in association with colloid) in case of hypovolemia or hypotension.

- Regulation or maintenance of metabolic acidosis balance and/or treatment of mild to moderate metabolic acidosis (except lactic acidosis).

4.2. Posology and method of administration

Posology

Recommended dosage:

The amount of Compound Sodium Lactate solution (Ringer Lactate solution) needed to restore normal blood volume is 3 to 5 times the volume of lost blood.

The recommended dosage depends on the weight, age and clinical condition. For routine maintenance of intravenous fluids, it is commonly within the following limits:

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

- for paediatrics: 20 ml to 100 ml/kg/24 h. Special clinical conditions, such as massive blood loss, burns, surgical drains, diarrhea, require additional adjustments of the necessary IV fluid volume.

Fluid balance, serum electrolytes and acid-base balance may need to be monitored before and during administration, with particular attention to serum sodium in patients with increased non- osmotic vasopressin release (syndrome of inappropriate antidiuretic hormone secretion, SIADH) and in patients co-medicated with vasopressin agonist drugs, due to the risk of hospital acquired hyponatraemia (see sections 4.4, 4.5 and 4.8).

Monitoring of serum sodium is particularly important for hypotonic fluids.

Administration rate:

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

For calculating the intravenous fluid maintenance rate in adults, a “4-2-1” rule can be used:

- 4 ml/kg/h for the first 10 kg of body weight,

- 2 ml/kg/h for the second 10 kg of body weight,

- 1 ml/kg/h for subsequent body weight.

For example, a 70 kg patient would require the following hourly maintenance fluid rate: 40+20+50=110 ml/h.

For calculating daily fluid maintenance rates in pediatric populations, the following algorithm can be applied:

- 100 ml/kg for infants of 3.5-10 kg body weight (except newborns of 0-28 days old),

- 1000 ml + 50 ml for every kg over 10 kg for children of 11-20 kg weight,

- 1500 ml + 20 ml/kg for every kg over 20 kg for children of >20 kg weight.

In patients with burns, the Parkland formula provides a basis for calculation of fluid requirements within the first 24 hours: 4 ml/kg/percentage of the body surface burned; onehalf to be given during the first 8 h and the second half in the next 16 h after the injury. The volume may be adjusted according to the patient's hemodynamic condition.

Pediatric patients may require larger volumes, especially in the presence of inhalational injury. Therefore, the estimation of the necessary fluid resuscitation therapy should be based on the monitored hemodynamics parameters, such as urine output, mental status, lactate level and base deficit.

Less liquid volume should be infused in patients:

- Having renal impairment,

- Having cardiac failure,

- Having severe hepatic insufficiency, especially with impaired lactate metabolism,

- Elderly.

Method of administration:

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

Hartmann's Solution tonicity: slightly hypotonic.

The infusion rate and volume depend on the age, weight, clinical condition (e.g. burns, surgery, headinjury, infections), and concomitant therapy should be determined by the consulting physician experienced in paediatric intravenous fluid therapy (see sections 4.4. and 4.8).

4.3. Contraindications

Do not administer in case of:

- 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 and treatment with potassium-sparing diuretics (see section 4.5)

4.4. Special warnings and precautions for use

The patient's clinical status and laboratory parameters (blood and urine electrolytes as well as acidbase 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 oedema, impaired renal function, pre- eclampsia, aldosteronism, or other conditions associated with sodium retention (see also section 4.5).

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 Ringer Lactate solution 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, Ringer lactate solution must not be administered via the same infusion system because of the risk of coagulation.

Ringer lactate solution may cause metabolic alkalosis because of the presence of lactate ions.

Ringer lactate solution 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.

High volume infusion must be used under specific monitoring in patients with cardiac or pulmonary failure, and in patients with non-osmotic vasopressin release (including SIADH), due to the risk of hospital-acquired hyponatraemia (see below).

Hyponatraemia

Patients with non-osmotic vasopressin release (e.g. in acute illness, pain, post-operative stress, infections, burns, and CNS diseases), patients with heart-, liver- and kidney diseases and patients exposed to vasopressin agonists (see section 4.5) are at particular risk of acute hyponatraemia upon infusion of hypotonic fluids.

Acute hyponatraemia can lead to acute hyponatraemic encephalopathy (cerebral oedema) characterized by headache, nausea, seizures, lethargy and vomiting. Patients with cerebral oedema are at particular risk of severe, irreversible and life-threatening brain injury.

Children, women in the fertile age and patients with reduced cerebral compliance (e.g. meningitis, intracranial bleeding, cerebral contusion and brain oedema) are at particular risk of the severe and lifethreatening brain swelling caused by acute hyponatraemia.

4.5. Interaction with other medicinal products and other forms of interaction

Drugs leading to an increased vasopressin effect

The below listed drugs increase the vasopressin effect, leading to reduced renal electrolyte free water excretion and may increase the risk of hospital acquired hyponatraemia following inappropriately balanced treatment with i.v. fluids (see sections 4.2, 4.4 and 4.8).

- Drugs stimulating vasopressin release include:

Chlorpropamide, clofibrate, carbamazepine, vincristine, selective serotonin reuptake inhibitors, 3.4methylenedioxy-N-methamphetamine, ifosfamide, antipsychotics, narcotics,

- Drugs potentiating vasopressin action include: Chlorpropamide, NSAIDs, cyclophosphamide,

- Vasopressin analogues include:

Desmopressin, oxytocin, vasopressin, terlipressin.

Other medicinal products increasing the risk of hyponatraemia also include diuretics in general and antiepileptics such as oxcarbazepine.

Interaction associated with sodium:

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

Interactions associated with calcium:

- Infusion in association with digitalis cardiac glycosides is contra-indicated because of the risk of severe to fatal cardiac arrhythmia particularly in the case of hypokalaemia

- Care should be taken in the concurrent use of thiazide diuretics or vitamin D because of the risk of hypercalcaemia resulting from reduced urinary clearance of calcium.

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

Interactions associated with potassium:

- Care should be taken in concurrent use of drugs containing potassium and drugs which have the potential for inducing hyperkalaemia, such as potassium-sparing diuretics given alone or in combination (such as spironolactone, triamterene, amiloride, potassium canrenoate), ACE inhibitors, angiotensin-II receptor antagonists, tacrolimus and ciclosporin.

Interaction associated with 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).

4.6. Fertility, pregnancy and lactation

Ringer Lactate solution can be used safely during pregnancy and lactation as long as the electrolyte- and fluid balance is controlled.

Hartmann's Solution should be administrated with special caution for pregnant women during labour particularly as to serum-sodium if administered in combination with oxytocin (see sections 4.4, 4.5 and 4.8).

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.

4.7. Effects on ability to drive and use machines

Not applicable

4.8. Undesirable effects

During administration of Ringer Lactate solution, 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/pruritus; skin swelling, periobial facial and/or laryngeal oedema (Quincke's oedema).

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 Ringer Lactate.

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

Electrolytes disturbances have been very commonly reported too.

Lactate infusions commonly induce feelings of anxiety, and a few cases of panic attack have been reported.

- frequency unkown :

Hospital acquired hyponatraemia*

Acute hyponatraemic encephalopathy*

*Hospital acquired hyponatraemia may cause irreversible brain injury and death, due to development of acute hyponatraemic encephalopathy (see sections 4.2, 4.4 and 4.5).

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.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important.

It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via:

Yellow Card Scheme

Website: www.mhra.gov.uk/yellowcard

4.9. Overdose

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.