Choice of Fluids in Critically Ill Patients

Claude Martin; Andrea Cortegiani; Cesare Gregoretti; Ignacio Martin-Loeches; Carole Ichai; Marc Leone; Gernot Marx; Sharon Einav

Disclosures

BMC Anesthesiol. 2018;18(200)

Conclusions

Intravenous fluids are drugs and should be prescribed as such. Among the available fluids, crystalloids have the highest benefit/risk ratio and, should generally be prescribed first. For critically ill patients or when large amount of fluids is expected to be infused, balanced solutions should be preferred because of their favourable effects on patient outcomes, including kidney function. The preferred solution for non critically ill patients or low volume resuscitation is less clear. However, given the availability of balanced solutions and their low cost, they could be considered for all patients. The role of albumin remains a matter of debate, but there is indirect evidence that albumin may favourably affect the outcomes of patients with septic shock. The indications and effects of gelatins remain unclear for critically ill patients. The role of dextrans in this patient population should probably remain marginal until more data is forthcoming.

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Abbreviations
AKI: Acute kidney injury; ARDS: Acute respiratory distress syndrome; CI: Cardiac index; CO: Cardiac output; CVP: Central venous pressure; EGDT: Early-goal directed therapy; GFR: Glomerular filtration rate; HES: Hydroxyethyl-starch; ICU: Intensive Care Unit; MFG: Modified fluid gelatine; NGAL: Neutrophil gelatinase-associated lipocain; PLR: Passive leg raising; RBF: Renal blood flow; RCT: Randomized controlled trial; SBP: Systolic blood pressure; SOFA: Sequential Organ Failure Assessment; SV: Stroke volume; TBI: Traumatic brain injury

Acknowledgments
We thank Dr. Iris Arad for her invaluable help with the literature search.

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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
Acetate Gluconate (Plasmalyte^®)	140	5	98	Gluconate (23)	294	50
Acetate Malate (Isofundin^®)	145	4	127	Acetate (24)	304	27
Acetate Malate (Isofundin^®)	145	4	127	Malate (5)	304	27
Colloids
Unbalanced
Hydroxyethylstarch (Voluven^®)	154	0	154	–	308	–
Albumin	154	0	154	–	308	–
Balanced
Hydroxyethylstarch (Tetraspan^®)	140	4	118	Acetate (24)	297	29
Hydroxyethylstarch (Tetraspan^®)	140	4	118	Malate (5)	297	29
Hydroxyethylstarch (Hextend^®)	143	3	124	–	307	28
Gelatins 4% (Plasmion^®)	154	0	120	–	307	32
Gelatins 3% (Gelofusin^®)	150	0	100	–	284	56

^aStrong Ion Difference

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

The table also reports the strenght of recomemantions and GRADE

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Choice of Fluids in Critically Ill Patients

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