Choice of Fluids in Critically Ill Patients

Background

Fluids are probably the most commonly administered intravenous treatment in inpatient care. Because of their excellent safety profile, until recently fluid solutions were not considered "medications".^[1] Little to no thought was therefore invested in the choice of fluids to be administered in specific clinical scenarios. However, recent evidence on long-term effects has altered our view on the different types of fluids available for fluid resuscitation. Intravenous fluids should be seen as drugs affecting the cardiovascular, renal, gastrointestinal and immune systems and should therefore not be administered "blindly".

Emphasis on the importance of volume above all the other characteristics of the fluids administered was nurtured by early guidelines that focused on administering specific fluid volumes to hemodynamically unstable patients (i.e. the surviving sepsis campaign).^[2,3] It is true that fluid administration is an important component of treatment of overt tissue hypoperfusion and hypoxia. Fluids may expand the intra-vascular compartment, thereby improving cardiac output (CO) and end-organ perfusion.^[3,4] However, the most common error with regards to fluid administration is the belief that resuscitation hinges on transfusion of a specific volume of fluids.^[3,5]

Disease processes are dynamic and their response to fluid may change over time. Specific disease states may also require different fluid therapy. Evidence from perioperative settings has associated both hypo- and hypervolemia with several unfavorable outcomes, including acute kidney injury (AKI), respiratory complications, increased lengths of stays, admission costs and 30-day-mortality rates.^[6,7] Later iterations of the guidelines have therefore clarified that the aim of fluid resuscitation is restoration of end-organ perfusion and correction of physiological imbalance. Follow-up during fluid administration should therefore include surrogate markers of organ perfusion (e.g. mean arterial pressure, central venous oxygen saturation, lactate, CO), markers of circulation, blood electrolyte and acid-base composition and indicators of renal function.^[3,8] No fluid is ideal for all disease conditions at all times. This review presents the current state of knowledge regarding the types of fluids to be administered with an emphasis on several disease states.

Table 1. The chemical composition of commonly used intravenous fluid solutions
Solutions	Na⁺(meq/L)	K⁺(meq/L)	Cl⁻(meq/L)	Other anions (meq/L)	Osmolarity (mosm/L)	In vivo SID^a (meq/L)
Crystalloids
Unbalanced
NaCl 0.9%	154	0	154	–	308	–
NaCl 3%	510	0	510	–	1026	–
NaCl 7.5%	1275	0	1275	–	2395	–
Balanced
Lactate Ringer	130	4	108	Lactate (27.6)	277	27
Acetate Ringer	132	4	110	Acetate (29)	277	27
Acetate Gluconate (Plasmalyte^®)	140	5	98	Acetate (27)	294	50
Gluconate (23)
Acetate Malate (Isofundin^®)	145	4	127	Acetate (24)	304	27
Malate (5)
Colloids
Unbalanced
Hydroxyethylstarch (Voluven^®)	154	0	154	–	308	–
Albumin	154	0	154	–	308	–
Balanced
Hydroxyethylstarch (Tetraspan^®)	140	4	118	Acetate (24)	297	29
Malate (5)
Hydroxyethylstarch (Hextend^®)	143	3	124	–	307	28
Gelatins 4% (Plasmion^®)	154	0	120	–	307	32
Gelatins 3% (Gelofusin^®)	150	0	100	–	284	56

Table 2. Guidelines on fluid management and resuscitation
Guideline title	Authors, year	Recommendations	Grade
Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016	Rhodes A. et al. 2017 [2]	We recommend that a fluid challenge technique be applied where fluid administration is continued as long as hemodynamic factors continue to improve	Best practice statement
We recommend crystalloids as the fluid of choice for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock	1B
We suggest using either balanced crystalloids or saline for fluid resuscitation of patients with sepsis or septic shock	2C
We suggest using albumin in addition to crystalloids for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock when patients require substantial amounts of crystalloids.	2C
We recommend against using hydroxyethyl starches (HESs) for intravascular volume replacement in patients with sepsis or septic shock	1A
We suggest using crystalloids over gelatins when resuscitating patients with sepsis or septic shock	2C
The clinical practice guideline for the management of ARDS in Japan	Hashimoto et al. 2017 [64]	We suggest fluid restriction in the management of adult patients with ARDS.	2B Weak recommendation Moderate quality evidence
Scandinavian clinical practice guidelines in fluid and drug therapy in adults with acure respiratory distress syndrome	Claesson et al. 2016 [65]	We suggest fluid restriction over a liberal fluid strategy in adults with ARDS	Weak recommendation Moderate quality evidence
European guideline on management of major bleeding and coagulopathy following trauma	Rossaint et al., 2016 [88]	We recommend that fluid therapy using isotonic crystalloid solutions be initiated in the hypotensive bleeding trauma patient	1A
We suggest that excessive use of 0.9% NaCl solution be avoided	2C
We recommend that hypotonic solutions such as Ringer's lactate be avoided in patients with severe head trauma	1C
We suggest the use of colloids be restricted due to the adverse effects on haemostasis	2C
AKI in the perioperative period & in ICU: french expert recommendations	Ichai C et al.2016 [111]	We recommend not administering hydroxyethylstarch (HES) in the ICU.STRONG agreement	1B
We suggest the preferential use of crystralloid instead of colloid for fluid loading.STRONG agreement	2A
We suggest preferring balanced solutions in case of large volume loading.STRONG agreement	2A
After hemodynamic stabilisation, we suggest avoiding fluid overload in the ICU.STRONG agreement	2A

Table 2. Guidelines on fluid management and resuscitation

Guideline title

Authors, year

Recommendations

Grade

Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016

Rhodes A. et al. 2017 [2]

We recommend that a fluid challenge technique be applied where fluid administration is continued as long as hemodynamic factors continue to improve

Best practice statement

We recommend crystalloids as the fluid of choice for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock

We suggest using either balanced crystalloids or saline for fluid resuscitation of patients with sepsis or septic shock

We suggest using albumin in addition to crystalloids for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock when patients require substantial amounts of crystalloids.

We recommend against using hydroxyethyl starches (HESs) for intravascular volume replacement in patients with sepsis or septic shock

We suggest using crystalloids over gelatins when resuscitating patients with sepsis or septic shock

The clinical practice guideline for the management of ARDS in Japan

Hashimoto et al. 2017 [64]

We suggest fluid restriction in the management of adult patients with ARDS.

2B
Weak recommendation
Moderate quality evidence

Scandinavian clinical practice guidelines in fluid and drug therapy in adults with acure respiratory distress syndrome

Claesson et al. 2016 [65]

We suggest fluid restriction over a liberal fluid strategy in adults with ARDS

Weak recommendation
Moderate quality evidence

European guideline on management of major bleeding and coagulopathy following trauma

Rossaint et al., 2016 [88]

We recommend that fluid therapy using isotonic crystalloid solutions be initiated in the hypotensive bleeding trauma patient

We suggest that excessive use of 0.9% NaCl solution be avoided

We recommend that hypotonic solutions such as Ringer's lactate be avoided in patients with severe head trauma

We suggest the use of colloids be restricted due to the adverse effects on haemostasis

AKI in the perioperative period & in ICU: french expert recommendations

Ichai C et al.2016 [111]

We recommend not administering hydroxyethylstarch (HES) in the ICU.STRONG agreement

We suggest the preferential use of crystralloid instead of colloid for fluid loading.STRONG agreement

We suggest preferring balanced solutions in case of large volume loading.STRONG agreement

After hemodynamic stabilisation, we suggest avoiding fluid overload in the ICU.STRONG agreement

Choice of Fluids in Critically Ill Patients

Background

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

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