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Fluid resuscitation in a nutshell

From Myburgh and Mythen’s marvellous monograph

 Myburgh, John A., and Michael G. Mythen.
‘Resuscitation Fluids’. 
New England Journal of Medicine 369, no. 13 (26 September 2013): 1243–1251. doi:10.1056/NEJMra1208627.

 Principles

  1. Fluid requirements change over time in critically ill patients.
  2. Fluids should be administered with the same caution that is used with any intravenous drug.
  3. Consider the type, dose, indications, contraindications, potential for toxicity, and cost.
  4. Remember the glycocalyx – be kind to it.

Type

  • Identify the fluid that is most likely to be lost and replace the fluid lost in equivalent volumes.
  • Consider serum sodium, osmolarity, and acid–base status when selecting a resuscitation fluid.

Dose and rate

  • Consider cumulative fluid balance and actual body weight when selecting the dose of resuscitation fluid.
  • The cumulative dose of resuscitation and maintenance fluids is associated with interstitial edema.
  • Pathological edema is associated with an adverse outcome.
  • Oliguria is a normal response to hypovolemia and should not be used solely as a trigger or end point for fluid resuscitation, particularly in the post-resuscitation period

Alternatives

  • Consider the early use of catecholamines as concomitant treatment of shock.

Specific considerations

  • Bleeding patients require control of hemorrhage and transfusion with red cells and blood components as indicated.
  • Isotonic, balanced salt solutions are a pragmatic initial resuscitation fluid for the majority of acutely ill patients.
  • Consider saline in patients with hypovolemia and alkalosis.
  • Consider albumin during the early resuscitation of patients with severe sepsis.
  • Saline or isotonic crystalloids are indicated in patients with traumatic brain injury.

Post-resuscitation period

  • The use of a fluid challenge in the post-resuscitation period (≥24 hours) is questionable.
  • The use of hypotonic maintenance fluids is questionable once dehydration has been corrected.

Beware

  • Albumin is not indicated in patients with traumatic brain injury.
  • Hydroxyethyl starch is not indicated in patients with sepsis or those at risk for acute kidney injury.
  • The safety of other semisynthetic colloids has not been established, so the use of these solutions is not recommended.
  • The safety of hypertonic saline has not been established.
  • The appropriate type and dose of resuscitation fluid in patients with burns has not been determined.

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