What are the different types of intravenous (IV) fluids used to treat hemorrhagic shock, including their respective advantages and benefits?

From the Guidelines

Crystalloids, such as balanced crystalloids or saline, are the recommended first-line fluid therapy for hemorrhagic shock, as they are readily available, inexpensive, and have a lower risk of adverse effects compared to colloids. The choice of fluid therapy in hemorrhagic shock depends on various factors, including the severity of shock, available resources, and patient response.

Types of IV Fluids

• Crystalloids:
  • First-line treatment for initial volume resuscitation
  • Advantages: Readily available, inexpensive, room temperature storage
  • Dose: Rapid infusion of 1-2 L, then titrate to response
  • Caution: May cause dilutional coagulopathy and edema with large volumes
• Colloids:
  • Second-line treatment when crystalloids are insufficient
  • Advantages: Longer intravascular retention, less volume needed
  • Dose: Typically 500-1000 mL
  • Caution: More expensive, potential renal effects with starches
• Blood products:
  • Essential for addressing coagulation deficits and oxygen-carrying capacity
  • Types: Packed Red Blood Cells (PRBCs), Fresh Frozen Plasma (FFP), Platelets, Cryoprecipitate

Recommendations

• Balanced crystalloids are probably recommended over 0.9% NaCl as first-line fluid therapy to reduce mortality and/or adverse renal events 1
• Early use of blood products in a balanced ratio (1:1:1 of PRBCs:FFP:Platelets) is recommended for severe hemorrhagic shock to address both volume and coagulation deficits 1
• Colloids, such as hydroxyethyl starch, are not recommended as first-line therapy due to potential renal effects and lack of benefit in reducing mortality 1
• Hypertonic saline solutions may be considered in specific situations, such as traumatic brain injury, but their use is not recommended as a first-line therapy 1

From the FDA Drug Label

For treatment of hypovolemic shock, the volume administered and the speed of infusion should be adapted to the response of the individual patient. Plasbumin-25 is hyperoncotic and on intravenous infusion will expand the plasma volume by an additional amount, three to four times the volume actually administered, by withdrawing fluid from the interstitial spaces, provided the patient is normally hydrated interstitially or there is interstitial edema. Although Plasbumin-5 is to be preferred for the usual volume deficits, Plasbumin-25 with appropriate crystalloids may offer therapeutic advantages in oncotic deficits or in long-standing shock where treatment has been delayed.

The different types of IV fluids used to treat hemorrhagic shock include:

• Crystalloids: used to restore the depleted extracellular fluid volume, especially in the first 24 hours after sustaining thermal injury.
• Colloids: such as Plasbumin-25 (albumin) and hydroxyethyl starch, which can help maintain plasma colloid osmotic pressure and expand plasma volume. The advantages and benefits of these IV fluids include:
• Rapid volume expansion: Plasbumin-25 can expand plasma volume by three to four times the volume administered.
• Improved hemodynamics: IV fluids can help improve blood pressure and cardiac output in patients with hypovolemic shock.
• Support of blood volume: albumin infusions can help support blood volume in patients with cirrhosis or other conditions that cause hypovolemia. However, the choice of IV fluid and the dosage should be adapted to the individual patient's response and underlying condition, and caution should be exercised to avoid circulatory overload and other complications 2, 2.

From the Research

Types of Intravenous (IV) Fluids

The different types of IV fluids used to treat hemorrhagic shock include:

• Crystalloid solutions, such as normal saline (NS), lactated Ringer's (LR), and Plasma-lyte A (PA) 3, 4, 5, 6
• Colloid solutions, such as succinylated gelatin (GEL) and hydroxyethyl starch (HES) 4
• Hypertonic saline (HTS) 4, 7
• Oxygen-carrying blood substitutes 3

Advantages and Benefits of Each Type of Fluid

The advantages and benefits of each type of fluid are:

• Crystalloid solutions:
  • Normal saline (NS): easily available and inexpensive, but may cause hyperchloremic acidosis and dilutional coagulopathy 6
  • Lactated Ringer's (LR): may be superior to NS in the resuscitation of uncontrolled hemorrhagic shock, with less hyperchloremic acidosis and dilutional coagulopathy 6
  • Plasma-lyte A (PA): may be better at correcting acid-base balance and improving intestine injury during hemorrhagic shock than NS and LR 5
• Colloid solutions:
  • Succinylated gelatin (GEL) and hydroxyethyl starch (HES): may restore intestinal microcirculatory blood flow, but may also increase reperfusion-induced renal reactive oxygen species formation 4
• Hypertonic saline (HTS):
  • May increase cardiac output with less net fluid, decrease pulmonary vascular resistance, and not result in more edema formation compared to lactated Ringer's 7
  • May restore intestinal microcirculatory blood flow 4

Considerations for Fluid Resuscitation

When choosing a fluid for resuscitation, considerations include:

• The type and severity of hemorrhagic shock
• The patient's underlying medical conditions and comorbidities
• The potential risks and benefits of each type of fluid, including the risk of hyperchloremic acidosis, dilutional coagulopathy, and reperfusion-induced renal reactive oxygen species formation 3, 4, 5, 6, 7