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Intravenous Fluid Therapy in Critical Illness

GINA HURST, MD

DIVISION OF EMERGENCY CRITICAL CARE

HENRY FORD HOSPITAL

DETROIT, MI

Objectives

▪ Establish goals of IV fluid therapy

▪ Review fluid types and availability

▪ Understand the concept of balanced solutions

▪ Discuss potential effects of hyperchloremia in the critically ill

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▪ Therapeutic efficacy

▪ Predictable response

▪ Low side effect profile

▪ Safety

▪ Suitability

▪ Ease of administration

▪ Cost

Intravenous Fluids

Intravenous fluids

▪ Indication

What is my therapeutic goal??

▪ Type

▪ Dose

Restore volume

Maintain homeostasis

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Intravenous fluids

▪ Indication

What is my therapeutic goal??

▪ Type

Ideal: close chemical composition to circulating plasma

▪ Dose

Restore volume

Maintain homeostasis

Plasma Composition ▪

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Intravenous fluids Solute Plasma Dextran Gelatin Albumin

5%

Normal

Saline

Ringer’s

lactate

Hartmann

solution

Plasma-

lyte

Na+ 135-145 154 154 145 154 130 131 140

K+ 4-5 0 0 0 0 4.5 5 5

Ca2+ 2.2-2.6 0 0 0 0 2.7 4 0

Mg2+ 1-2 0 0 0 0 0 0 1.5

Cl- 95-110 154 120 145 154 109 111 98

Acetate 0 0 0 0 0 0 0 27

Lactate 0.8-1.8 0 0 0 0 28 29 0

Gluconate 0 0 0 0 0 0 0 23

Bicarbonate 23-26 0 0 0 0 0 0 0

Osmolarity 291 308 274 ~300 308 280 279 294

Colloid 35-45 100 40 50g 0 0 0 0

Colloid resuscitation: Hetastarch

▪ 6S trial – HES vs LR

▪ increased 90 d mortality,

▪ Increased need for RRT

▪ Increased rate of blood product transfusion

▪ CHEST – HES vs NS

▪ Increased AKI and need for RRT

▪ No difference in mortality

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Colloid resuscitation: Albumin

▪ SAFE – Albumin vs NS

▪ Albumin better in sepsis

▪ No difference in mortality

▪ CRISTAL – Colloid vs NS

▪ No difference in 28 d mortality

▪ Possible increase in 90 d mortality with colloid

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Crystalloid: 0.9 % Normal Saline

▪ 154 mEq of NaCl/L

▪ 287 mOsm/kg

▪ pH of 5.5-6

▪ 0.9% NaCl solution isotonic in vitro

▪ Non-physiologic ion content

▪ Lack of buffering capacity

Crystalloid: Balanced Solutions

▪ Organic anions

▪ Lactate, acetate, gluconate

▪ Buffering capabilities

▪ Calcium

▪ Magnesium

▪ Potassium

Ringer’s

lactate

Hartmann

solution

Plasma-

lyte

130 131 140

4.5 5 5

2.7 4 0

0 0 1.5

109 111 98

0 0 27

28 29 0

0 0 23

0 0 0

280 279 294

6.5 6.5 7.4

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Fluid Choice and In-hospital MortalityRaghunathan et al Crit Care Med 2014; 42:1585-1591

Mortality is lowest in group receiving greatest amount of balanced solutions

Raghunathan et al Crit Care Med 2014; 42:1585-1591

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Impact of IV fluid composition on outcomes in patients with SIRS

Shaw et. al Critical Care 2015; 19:334

▪ Saline cohort with greater in-hospital mortality (3.27% compared to 1.03%)

Balanced vs. 0.9 NS

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Claims against hyperchloremia

▪ Metabolic Acidosis

▪ Increased inflammatory cytokines

▪ Renal vasoconstriction

▪ Decreased renal blood flow/diuresis/natiuresis

▪ Increased interstitial edema

▪ Possible coagulopathy

Metabolic acidosisInflammatory cytokines

▪ Hyperchloremia with acidosis due to change in strong ion difference

▪ SID=[(Na+K+Mg+Ca) – (Cl+lactate)]

▪ Animal studies correlate increasing hyperchloremia with worsening hemodynamic profile and inflammation

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Metabolic acidosisInflammatory cytokines

▪ Increasing acidemiaassociated with elevation in:

▪ IL-6▪ IL-10▪ TNFa

Kellum et al CHEST 2006 130;4:962-7

Claims against hyperchloremia

▪ Metabolic Acidosis

▪ Increased inflammatory cytokines

▪ Renal vasoconstriction

▪ Decreased renal blood flow/diuresis/natiuresis

▪ Increased interstitial edema

▪ Possible coagulopathy

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Effect of hyperchloremia on renal function

Effect of hyperchloremia on renal function

▪ Rat model of shock (Almac et al

Resuscitation 2012; 83:1166-72)

▪ Hyperchloremia/acidemiamore profound in NS group

▪ Normal saline group with lowest creatinine clearance and lowest renal blood flow after resuscitation.

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Effect of hyperchloremia on renal function

▪ Healthy human subjects (Chowdhury Ann Surg 2012;256:18-24)

▪ NS vs plasmalyte

▪ NS with increased time to micturition

▪ NS with decreased UOP.

▪ Renal blood flow

▪ NS decrease in mean flow by 9%

▪ Cortical tissue perfusion

▪ NS decrease perfusion by 11.7%

Effect of hyperchloremia on renal function

▪ Chloride liberal IVF (Yunos et al. JAMA 2012 308;15:1566-72)

▪ Increased risk of AKI and use of RRT ▪ OR 0.52

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Normal Saline Preferred

▪ Traumatic brain injury▪ LR with decrease in serum osm comp to NS

▪ 287 +/-4 vs. 290 +/-5 (Williams Anesth Analg 1999;88:999-1003)

▪ Worsening cerebral water content and ICP in animal models Shackford J Neurosurg 1992;72:91-98

Zornow Anesth 1987;67:936-41

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Summary

▪ Balanced IV fluids are preferred for large volume resuscitation

▪ Hyperchloremia is increasingly shown to be associated with morbidity and mortality

▪ TBI or other risk of ICP should be treated with NS

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Use your fluids wisely!