LACTATED RINGERS- sodium chloride, sodium lactate, potassium chloride, calcium chloride injection, solution
LACTATED RINGERS by
Drug Labeling and Warnings
LACTATED RINGERS by is a Prescription medication manufactured, distributed, or labeled by Fresenius Kabi USA, LLC, Fresenius Kabi Norge As. Drug facts, warnings, and ingredients follow.
Drug Details [pdf]
- SPL UNCLASSIFIED SECTION
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DESCRIPTION:
Lactated Ringer's Injection, USP is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment in single dose containers for intravenous administration. It contains no antimicrobial agents. Composition, osmolarity, pH, ionic concentration and caloric content are shown in Table 1.
Table 1
Size (mL)Composition (g/L) Ionic Composition (mEq/L)
Caloric Content
(kcal/L)Sodium Chloride, USP (NaCl) Sodium Lactate, USP
(C 3H 5NaO 3)
Potassium Chloride, USP (KCl)Calcium Chloride, USP
(CaCl 22H 2O)
Osmolarity
(mOsmol/L)
(calc)
pH
Sodium
Potassium
Calcium
Chloride
LactateLactated Ringer's
Injection, USP250 6 3.1 0.3 0.2 273 6.5 (6.0 to 7.5) 130 4 2.7 109 28 9 500 1,000 The flexible container is fabricated from a specially formulated non-plasticized, film containing polypropylene and thermoplastic elastomers ( freeflex® bag). The amount of water that can permeate from inside the container into the overwrap is insufficient to affect the solution significantly. Solutions in contact with the flexible container can leach out certain of the container's chemical components in very small amounts within the expiration period. The suitability of the container material has been confirmed by tests in animals according to USP biological tests for plastic containers.
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CLINICAL PHARMACOLOGY:
Lactated Ringer's Injection has value as a source of water and electrolytes. It is capable of inducing diuresis depending on the clinical condition of the patient.
Lactated Ringer's Injection produces a metabolic alkalinizing effect. Lactate ions are metabolized ultimately to carbon dioxide and water, which requires the consumption of hydrogen cations.
- INDICATIONS AND USAGE:
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CONTRAINDICATIONS:
As for other calcium-containing infusion solutions, concomitant administration of ceftriaxone and Lactated Ringer's Injection is contraindicated in newborns (≤ 28 days of age), even if separate infusion lines are used (risk of fatal ceftriaxone-calcium salt precipitation in the neonate's bloodstream).
In patients older than 28 days (including adults), ceftriaxone must not be administered simultaneously with intravenous calcium-containing solutions, including Lactated Ringer's Injection, through the same infusion line (e.g., via Y-connector). If the same infusion line is used for sequential administration, the line must be thoroughly flushed between infusions with a compatible fluid.
Lactated Ringer's Injection is contraindicated in patients with a known hypersensitivity to sodium lactate.
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WARNINGS:
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 deficiency; therefore, it should not be used for this purpose.
Lactated Ringer's Injection is not for use for the treatment of lactic acidosis or severe metabolic acidosis.
Lactated Ringer's Injection should not be administered simultaneously with citrate anticoagulated/preserved blood through the same administration set because of the likelihood of coagulation.
The infusion must be stopped immediately if any signs or symptoms of a suspected hypersensitivity reaction develop. Appropriate therapeutic countermeasures must be instituted as clinically indicated. Hypersensitivity reactions are reported more frequently during pregnancy.
Depending on the volume and the rate of infusion, the intravenous administration of Lactated Ringer's Injection can cause fluid and/or solute overloading resulting in dilution of serum electrolyte concentrations, overhydration, congested states, pulmonary edema or acid-base imbalance. The risk of dilutional states is inversely proportional to the electrolyte concentrations of the injections. The risk of solute overload causing congested states with peripheral and pulmonary edema is directly proportional to the electrolyte concentrations of the injections.
Clinical evaluation and periodic laboratory determinations may be necessary to monitor changes in fluid balance, electrolyte concentrations, and acid base balance during prolonged parenteral therapy or whenever the condition of the patient or the rate of administration warrants such evaluation.
Lactated Ringer's Injection should be administered with particular caution, if at all, to patients with hyperkalemia or conditions predisposing to hyperkalemia (such as severe renal impairment or adrenocortical insufficiency, acute dehydration, or extensive tissue injury or burns) and in patients with cardiac disease.
Lactated Ringer's Injection should be administered with particular caution, if at all, to patients with alkalosis or at risk for alkalosis. Because lactate is metabolized to bicarbonate, administration may result in, or worsen, metabolic alkalosis.
Lactated Ringer's Injection should be administered with particular caution, if at all, to patients with severe renal impairment, hypervolemia, overhydration, or conditions that may cause sodium and/or potassium retention, fluid overload, or edema.
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PRECAUTIONS:
Do not connect flexible plastic containers in series in order to avoid air embolism due to possible residual air contained in the primary container.
Pressurizing intravenous solutions contained in flexible plastic containers to increase flow rates can result in air embolism if the residual air in the container is not fully evacuated prior to administration.
Use of a vented intravenous administration set with the vent in the open position could result in air embolism. Vented intravenous administration sets with the vent in the open position should not be used with flexible plastic containers.
Lactated Ringer's Injection should be administered with particular caution, if at all, to patients with conditions associated with increased lactate levels or impaired lactate utilization, such as severe hepatic insufficiency.
Hyperlactatemia can develop in patients with severe hepatic insufficiency, since lactate metabolism may be impaired. In addition, Lactated Ringer's Injection may not produce its alkalinizing action in patients with severe hepatic insufficiency, since lactate metabolism may be impaired.
Solutions containing calcium salts should be used with caution in patients with hypercalcemia or conditions predisposing to hypercalcemia, such as patients with severe renal impairment and granulomatous diseases associated with increased calcitriol synthesis such as sarcoidosis, calcium renal calculi or history of such calculi.
Lactate is a substrate for gluconeogenesis. This should be taken into account when Lactated Ringer's Injection is used in patients with type 2 diabetes.
Pediatric Use
Safety and effectiveness of Lactated Ringer's Injection in pediatric patients have not been established by adequate and well controlled trials, however, the use of electrolyte solutions in the pediatric population is referenced in the medical literature. The warnings, precautions and adverse reactions identified in the label copy should be observed in the pediatric population.
Lactate-containing solutions should be administered with particular caution to neonates and infants less than 6 months of age.
Geriatric Use
Clinical studies of Lactated Ringer's Injection did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.
Drug Interactions
Ceftriaxone (see CONTRAINDICATIONS).
Caution is advised when administering Lactated Ringer's Injection to patients treated with drugs that may increase the risk of sodium and fluid retention, such as corticosteroids.
Caution is advised when administering Lactated Ringer's Injection to patients treated with drugs for which renal elimination is pH dependent. Due to the alkalinizing action of lactate (formation of bicarbonate), Lactated Ringer's Injection may interfere with the elimination of such drugs.
- Renal clearance of acidic drugs such as salicylates and barbiturates may be increased.
- Renal clearance of alkaline drugs, such as sympathomimetics (e.g., ephedrine, pseudoephedrine) and dextroamphetamine (dexamphetamine) sulfate, may be decreased.
Renal clearance of lithium may also be increased. Caution is advised when administering Lactated Ringer's Injection to patients treated with lithium.
Because of its potassium content, Lactated Ringer's Injection should be administered with caution in patients treated with agents or products that can cause hyperkalemia or increase risk of hyperkalemia, such as potassium sparing diuretics (amiloride, spironolactone, triamterene), with ACE inhibitors, angiotensin II receptor antagonists, or the immunosuppressants tacrolimus and cyclosporine.
Caution is advised when administering Lactated Ringer's Injection to patients treated with thiazide diuretics or vitamin D, as these can increase the risk of hypercalcemia.
Pregnancy
Teratogenic Effects
Pregnancy Category C.
Animal reproduction studies have not been conducted with Lactated Ringer's Injection. It is also not known whether Lactated Ringer's Injection can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Lactated Ringer's Injection should be given to a pregnant woman only if clearly needed.
For Hypersensitivity Reactions During Pregnancy (see WARNINGS).
Carcinogenesis, Mutagenesis, Impairment of Fertility
Long-term studies in animals to evaluate carcinogenic potential or studies to evaluate mutagenic potential have not been performed with Lactated Ringer's Injection. Studies to evaluate the possible impairment of fertility have not been performed.
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ADVERSE REACTIONS:
Post-Marketing Adverse Reactions
The following adverse reactions have been reported in the post-marketing experience, listed by MedDRA System Organ Class (SOC).
Immune System Disorders
Hypersensitivity/infusion reactions, including anaphylactic/anaphylactoid reactions, and the following manifestations: angioedema, chest pain, chest discomfort, decreased heart rate, tachycardia, blood pressure decreased, respiratory distress, bronchospasm, dyspnea, cough, urticaria, rash, pruritus, erythema, flushing, throat irritation, paresthesia, hypoesthesia oral, dysgeusia, nausea, anxiety, pyrexia, headache.
Class Reactions
Hypersensitivity reactions, including, laryngeal edema and sneezing
Hypervolemia
Infusion site reactions, including infection at the site of injection, extravasation, and infusion site anesthesia (numbness)
Overdose
An excessive volume or too high a rate of administration of Lactated Ringer's Injection may lead to fluid and sodium overload with a risk of edema (peripheral and/or pulmonary), particularly when renal sodium excretion is impaired.
Excessive administration of lactate may lead to metabolic alkalosis. Metabolic alkalosis may be accompanied by hypokalemia.
Excessive administration of potassium may lead to the development of hyperkalemia, especially in patients with severe renal impairment.
Excessive administration of calcium salts may lead to hypercalcemia.
When assessing an overdose, any additives in the solution must also be considered.
The effects of an overdose may require immediate medical attention and treatment.
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DOSAGE AND ADMINISTRATION:
As directed by a physician. Dosage, rate and duration of administration are to be individualized and dependent upon the indication for use, the patient's age, weight, concomitant treatment and clinical condition of the patient as well as laboratory determinations.
All injections in flexible plastic containers are intended for intravenous administration using sterile and nonpyrogenic equipment.
After opening the container, the contents should be used immediately and should not be stored for a subsequent infusion. Do not reconnect any partially used containers.
Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration whenever solution and container permit. Do not administer unless the solution is clear and seal is intact.
When making additions to Lactated Ringer's Injection, aseptic technique must be used. Mix the solution thoroughly when additives have been introduced. Do not store solutions containing additives.
Additives may be incompatible with Lactated Ringer's Injection. As with all parenteral solutions, compatibility of the additives with the solution must be assessed before addition, by checking for a possible color change and/or the appearance of precipitates, insoluble complexes, or crystals. Before adding a substance or medication, verify that it is soluble and/or stable in water and that the pH range of Lactated Ringer's Injection is appropriate.
The instructions for use of the medication to be added and other relevant literature must be consulted. Additives known or determined to be incompatible should not be used.
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HOW SUPPLIED:
Lactated Ringer's Injection, USP in a single dose flexible plastic container, is available as follows:
Product Each Unit of Sale 964174 NDC: 63323-164-24
One 250 mL freeflex® BagNDC: 63323-164-74
Sold in units of 30964175 NDC: 63323-164-25
One 500 mL freeflex® BagNDC: 63323-164-75
Sold in units of 20964176 NDC: 63323-164-26
One 1,000 mL freeflex® BagNDC: 63323-164-76
Sold in units of 10Exposure of pharmaceutical products to heat should be minimized. Avoid excessive heat.
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INSTRUCTIONS FOR USE:
Check flexible container solution composition, lot number, and expiry date.
Do not remove solution container from its overwrap until immediately before use.
Use sterile equipment and aseptic technique.
To Open
- Turn solution container over so that the text is face down. Using the pre-cut corner tabs, peel open the overwrap and remove solution container.
- Check the solution container for leaks by squeezing firmly. If leaks are found, or if the seal is not intact, discard the solution.
- Do not use if the solution is cloudy or a precipitate is present.
Preparation for Administration
- Immediately before inserting the infusion set, break off BLUE Infusion Port Cap with the arrow pointing away from container.
- Use a non-vented infusion set or close the air-inlet on a vented set.
- Close the roller clamp of the infusion set.
- Hold the base of BLUE Infusion Port.
- Insert spike through BLUE Infusion Port by rotating wrist slightly until the spike is inserted. NOTE: See full directions accompanying administration set.
To Add Medication Prior to Solution Administration
- Identify WHITE Additive Port with arrow pointing toward container.
- Immediately before injecting additives, break off WHITE Additive Port Cap with the arrow pointing toward container.
- Hold base of WHITE Additive Port horizontally.
- Prepare medication site.
- Insert an 18 to 23 gauge needle horizontally through the center of WHITE Additive Port's septum and inject additives.
- Mix container contents thoroughly. For high density medication such as potassium chloride, squeeze ports while ports are upright and mix thoroughly.
To Add Medication During Solution Administration
- Close the clamp on the set.
- Identify WHITE Additive Port with arrow pointing toward container.
- Immediately before injecting additives, if the Cap has not been broken off, break off WHITE Additive Port Cap with the arrow pointing toward container.
- Hold base of WHITE Additive Port horizontally.
- Prepare medication site.
- Using a syringe with an 18 to 23 gauge needle, horizontally insert through the center of WHITE Additive Port's septum and inject additives.
- Remove container from IV pole and/or turn to an upright position.
- Mix container contents thoroughly.
- Using aseptic technique, repeat steps 4-7 as necessary.
- Return container to in use position and continue administration.
WARNING: Do not use flexible container in series connections.
Manufactured for:
Lake Zurich, IL 60047
Made in Norway
www.fresenius-kabi.com/us
451533
Issued: November 2018 -
PRINCIPAL DISPLAY PANEL
PACKAGE LABEL - PRINCIPAL DISPLAY – Lactated Ringer's Injection, USP 250 mL Bag
NDC: 63323-164-24
250 mL Lactated Ringer's Injection, USP
For intravenous use. Rx only
mEq/L:
Each 100 mL contains: Na + 130
Sodium Chloride, USP 600 mg K + 4
Sodium Lactate, USP 310 mg Ca 2+ 2.7
Potassium Chloride, USP 30 mg Cl - 109
Calcium Chloride, USP 20 mg Lactate 28
273 mOsmol/L (calc.) pH 6.5 (6.0 to 7.5)
Single Dose Only. Discard Unused Portion.
Not for use in the treatment of lactic acidosis.
Additives may be incompatible. Consult with pharmacist. When introducing additives,
use aseptic technique, mix thoroughly and do not store. Use only if solution is clear
and container is undamaged. Must not be used in series connections. Do not administer simultaneously with blood.Usual dosage: See package insert.
The overwrap is a moisture barrier.
Use immediately once removed from overwrap.
STORE AT: 20° to 25°C ( 68° to 77°F) [see USP Controlled Room Temperature].
Avoid excessive heat.The container closure is not made with natural rubber latex.
Non-PVC, Non-DEHP, Sterile.
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INGREDIENTS AND APPEARANCE
LACTATED RINGERS
sodium chloride, sodium lactate, potassium chloride, calcium chloride injection, solutionProduct Information Product Type HUMAN PRESCRIPTION DRUG Item Code (Source) NDC: 63323-164 Route of Administration INTRAVENOUS Active Ingredient/Active Moiety Ingredient Name Basis of Strength Strength SODIUM CHLORIDE (UNII: 451W47IQ8X) (SODIUM CATION - UNII:LYR4M0NH37, CHLORIDE ION - UNII:Q32ZN48698) SODIUM CHLORIDE 600 mg in 100 mL SODIUM LACTATE (UNII: TU7HW0W0QT) (SODIUM CATION - UNII:LYR4M0NH37, LACTIC ACID - UNII:33X04XA5AT) SODIUM LACTATE 310 mg in 100 mL POTASSIUM CHLORIDE (UNII: 660YQ98I10) (POTASSIUM CATION - UNII:295O53K152, CHLORIDE ION - UNII:Q32ZN48698) POTASSIUM CHLORIDE 30 mg in 100 mL CALCIUM CHLORIDE (UNII: M4I0D6VV5M) (CALCIUM CATION - UNII:2M83C4R6ZB, CHLORIDE ION - UNII:Q32ZN48698) CALCIUM CHLORIDE 20 mg in 100 mL Inactive Ingredients Ingredient Name Strength WATER (UNII: 059QF0KO0R) Packaging # Item Code Package Description Marketing Start Date Marketing End Date 1 NDC: 63323-164-74 30 in 1 CASE 01/28/2019 1 NDC: 63323-164-24 250 mL in 1 BAG; Type 0: Not a Combination Product 2 NDC: 63323-164-75 20 in 1 CASE 01/28/2019 2 NDC: 63323-164-25 500 mL in 1 BAG; Type 0: Not a Combination Product 3 NDC: 63323-164-76 10 in 1 CASE 01/28/2019 3 NDC: 63323-164-26 1000 mL in 1 BAG; Type 0: Not a Combination Product Marketing Information Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date ANDA ANDA209338 01/28/2019 Labeler - Fresenius Kabi USA, LLC (608775388) Establishment Name Address ID/FEI Business Operations Fresenius Kabi Norge As 731170932 manufacture(63323-164)
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