* Brief Summary: Fluid Resuscitation in the Critically Ill - There has been a large amount of recent research focusing on which IV fluids should be used to resuscitate a critically ill patient. Here is a brief summary to date: I- Crystalloids: A- Normal Saline: • Contains a supraphysiologic concentration of chloride so it reliably induces a hyperchloremic metabolic acidosis. • This may be harmful since this phenomenon induces immune dysfunction and also causes renal vasoconstriction with a decline in GFR. • Although the clinical consequences of these effects is not completely certain, there is literature indicating they are clinically important. B- Balanced Solutions: • Because of the adverse effects of NS, balanced solutions are becoming the crystalloid of choice in many centers for the resuscitation of critically ill patients. • Balanced solutions are crystalloids that achieve lower chloride concentrations by adding an organic ion (e.g. lactate) to balance the pH and typically add cations (K+, Mg+,Ca+) . 1- Plasma-Lyte: - Is a slightly alkalotic IV fluid and may be preferable in patients with an existing metabolic acidosis. - Recent literature suggests benefits over NS in patients with DKA, in trauma patients, and in septic patients. 2- Lactated Ringers: - Has a low sodium concentration, so it likely should be avoided in hyponatremic patients, and patients with traumatic brain injury. - As it contains calcium, it may generate microthrombi with citrate-containing red-cell transfusions. II- Colloids: - Contrary to what had been long believed, colloids are not significantly more effective in expanding intravascular volume as compared to crystalloids in patients with a systemic inflammatory state such as sepsis. - Currently, there does not appear to be any benefit to colloid use in the ICU/ED. A- Albumin: • The current Surviving Sepsis guidelines recommend albumin as an adjunct to crystalloids when patients require substantial amounts of crystalloids. • Recent literature suggests that, in fact, there is no mortality benefit in sepsis. • In acute illness, the hemodynamic effects and effects on patient-centered outcomes of albumin are largely equivalent to those of saline. B- Hetastarch or Hydroxyethyl Starch: • In light of current evidence of the lack of clinical benefit and increased cost, its use in critically ill patients is difficult to justify. - References: (1) Myburgh JA, et al. N Engl J Med 2013 Sep 26; 369(13): 1243-51. (2) Shaw AD, et al. Ann Surg 2012 May;255(5):821-9. (3) Yunos NM, et al. JAMA 2012 Oct 17;308(15):1566-72. (4) Mahler SA, et al. Am J Emerg Med 2011 Jul;29(6):670-4. (5) Young JB, et al. Ann Surg 2014 Feb;259(2):255-62. (6) Raghunathan K, et al. Crit Care Med. 2014 Mar 26. [Epub ahead of print] (7) Caironi P, et al. N Engl J Med  2014 Apr 10;370(15):1412-21.
Posted on: Mon, 25 Aug 2014 08:37:09 +0000
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