Recommendations for Fluid Resuscitation in Acutely Ill Patients

Although the use of resuscitation fluids is one of the most common interventions in medicine, no currently available resuscitation fluid can be considered to be ideal. In light of recent high quality evidence, a reappraisal of how resuscitation fluids are used in acutely ill patients is now required. The selection, timing, and doses of intravenous fluids should be evaluated as carefully as they are in the case of any other intravenous drug, with the aim of maximizing efficacy and minimizing iatrogenic toxicity.

Recommendations for Fluid Resuscitation in Acutely Ill Patients.
Fluids should be administered with the same caution that is used with any intravenous drug.

  • Consider the type, dose, indications, contraindications, potential for toxicity, and cost.

Fluid resuscitation is a component of a complex physiological process.

  • 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.
  • Consider cumulative fluid balance and actual body weight when selecting the dose of resuscitation fluid.
  • Consider the early use of catecholamines as concomitant treatment of shock.

Fluid requirements change over time in critically ill patients.

  • 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.
  • 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.

Specific considerations apply to different categories of patients.

  • 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.
  • 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.

 

 

References:

  1. Myburgh JA, Mythen MG. Resuscitation Fluids. N Engl J Med 2013;369:1243-51. [Medline]
  2. Wujtewicz M. Fluid use in adult intensive care. Anaesthesiol Intensive Ther. 2012 Aug 8;44(2):92-5.[Medline]

Created Sep 26, 2013.