Shock Intravenous Fluid Resuscitation Almost all circulatory shock states require large-volume IV fluid replacement, as does severe intravascular volume depletion eg, due to diarrhea or heatstroke. Intravascular volume deficiency is acutely compensated for by vasoconstriction, followed over hours by migration of fluid from the extravascular compartment to the intravascular compartment, maintaining circulating volume at the expense of total body water. However, this compensation is overwhelmed after major losses. See Water and Sodium Balance for maintenance fluid requirement discussion, and see Dehydration and Fluid Therapy in Children for mild dehydration discussion.
Nine reasons to quit using normal saline for resuscitation February 27, Saline vs. Two fresh studies will illuminate this: This post summarizes current knowledge, beginning with physiology and working our way to fresh trials.
There is no physiologic reason that infusing it into people is a smart idea. Rather than any scientific rationale, the reasons for using saline boil down to the following: Everyone in the department uses it. It's how I was trained. It seems to work. The nurses start it automatically.
These are foolish justifications: The cost difference between a liter of saline and liter of lactated ringers LR is about 25 cents.
This belief reflects status quo bias — assuming that conventional therapy is superior. Saline exacerbates acidosis Saline causes hyperchloremic acidosis. Some patients we resuscitate are severely acidemic to begin with. It is irresponsible to give them a fluid which will exacerbate their acidemia.
If saline is used as the default resuscitative fluid, then it will be given to acidemic patients before their labs return. Healthcare systems should be designed to avoid causing harm. Using saline as a default fluid is a poor choice, because it will inevitably lead to a situation where a severely acidemic patient is given an acidic fluid, causing deterioration.
This is a failing at the system level. The fix is to use a balanced crystalloid as the default resuscitative fluid. Balanced fluids will always pull the patient's pH towards normalcy, so they are safe regardless of the patient's electrolytes 2.
Saline may be dangerous in hyperkalemia Traditional dogma is that LR is unsafe in hyperkalemia. This myth has been debunked here a widely read post which has been translated by European physicians into both German and French. Evidence suggests the exact opposite of traditional dogma: The reason for this is that saline causes acidosis, causing potassium to shift into the blood.
From a physiologic standpoint, it ought to be universal. For example, Martini found similar results when comparing LR vs. NR in a pig model of hemorrhagic shock. However, patients with adequate renal function may be able to compensate for potassium entering the blood.
Hyperchloremic acidosis causes harm in animal models It's indisputable that saline causes hyperchloremic acidosis. However, the effects of mild hyperchloremic acidosis are debated.
Is this clinically significant, or just an abnormal number? Kellum evaluated the effect of hyperchloremic acidosis in septic rats. Acidosis was produced by infusing hydrochloric acid at two different concentrations, compared to an equal volume of LR as the control. Acid infusion decreased blood pressure, which isn't too surprising figure below.
This suggests that in the context of sepsis, even mild hyperchloremic acidosis is harmful. Orbegozo performed a study comparing NS vs. Plasmalyte in a sheep model of septic shock. Sheep treated with NS fared poorly: Greater acidosis Reduced muscle tissue oxygen levels Impaired microcirculatory perfusion Earlier development of oliguria Earlier death This study proves that hyperchloremic acidosis due to saline can cause harm.
Differences emerged when electrolytes were only slightly altered, again suggesting that mild hyperchloremic acidosis may be dangerous. Saline may cause hemodynamic instability Potura performed a RCT on patients undergoing renal transplantation randomized to receive saline vs.
Elomel Isoton solution an acetate-buffered balanced crystalloid 3. However, this was a secondary endpoint.Modern ideas include avoiding excessive crystalloid fluid resuscitation by allowing permissive hypotension and early use of blood and massive transfusion protocols with damage control surgery to combat the lethal triad .
Early, goal-directed therapy (EGDT) is recommended in international guidelines for the resuscitation of patients presenting with early septic shock. However, adoption has been limited, and. Hypovolemia is a state of decreased blood volume; more specifically, decrease in volume of blood plasma.
It is thus the intravascular component of volume contraction (or loss of blood volume due to things such as bleeding or dehydration), but, as it also is the most essential one, hypovolemia and volume contraction are sometimes used synonymously.
Apr 27, · Aggressive fluid resuscitation during the Vietnam War with red blood cells, plasma, and crystalloid solutions allowed patients who previously would have succumbed to hemorrhagic shock to survive.
Background: The best way to resuscitate critically ill patients with fluids has been a hotly debated topic in the FOAMed and Critical Care worlds. Fluids are important to optimize stroke volume and distal tissue perfusion, however, the administration of excessive fluids for shock can increase a patient’s morbidity and mortality by causing volume overload, which may lead to tissue edema and.
1 Stony Brook Medicine Severe Sepsis/Septic Shock Recognition and Treatment Protocols Subject: Severe Sepsis/Septic Shock Published Date: August 9,