What isotonic fluid is recommended for a patient presenting with sepsis, dehydration, and hyperchloremia?

From the Guidelines

For a patient with sepsis, dehydration, and hyperchloremia, balanced crystalloid solutions such as Lactated Ringer's (LR) or Plasma-Lyte are the preferred isotonic fluids. These fluids have electrolyte compositions that more closely resemble plasma than normal saline (0.9% NaCl), with lower chloride concentrations (109 mEq/L in LR vs 154 mEq/L in normal saline) 1. Using normal saline in a hyperchloremic patient would worsen the existing electrolyte imbalance and potentially lead to hyperchloremic metabolic acidosis. Balanced solutions help correct dehydration while avoiding further chloride load.

Key Considerations

• The typical initial resuscitation for sepsis involves rapid administration of 30 mL/kg of balanced crystalloids within the first 3 hours, followed by additional fluid guided by hemodynamic assessment 1.
• Lactated Ringer's has the added benefit of containing lactate, which converts to bicarbonate in the liver, potentially helping to correct metabolic acidosis often present in sepsis.
• Monitor electrolytes, acid-base status, and kidney function during resuscitation, as fluid requirements may change based on the patient's response to initial therapy.

Recommendations

• Use balanced crystalloids as the initial fluid of choice for resuscitation in patients with sepsis and septic shock 1.
• Avoid using hydroxyethyl starches for intravascular volume replacement in patients with sepsis or septic shock 1.
• Consider using albumin in addition to crystalloids for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock, when patients require substantial amounts of crystalloids 1.

From the FDA Drug Label

If the patient is dehydrated, additional crystalloids must be given,(4) or alternatively, Albumin (Human) 5%, USP (Plasbumin®-5) should be used.

The patient is presenting with sepsis and dehydration but is hyperchloremic. In this case, the choice of isotonic fluid is crucial.

• The patient's dehydration status indicates the need for fluid resuscitation.
• The patient's hyperchloremic status suggests that a balanced isotonic fluid with a lower chloride concentration may be preferred to avoid exacerbating the condition.
• Albumin (Human) 5%, USP (Plasbumin®-5) may be considered as an alternative to crystalloids in dehydrated patients 2. However, the FDA drug label does not provide a direct answer to which specific isotonic fluid to use in this scenario.

From the Research

Fluid Resuscitation in Sepsis

• The administration of isotonic crystalloid fluid is a key component of the initial resuscitation of septic shock, with international consensus guidelines suggesting the administration of at least 30mL/kg of isotonic crystalloid fluid 3.
• In patients presenting with sepsis, dehydration, and hyperchloremia, the choice of isotonic fluid is crucial to avoid exacerbating the hyperchloremia.
• Balanced crystalloids, such as lactated Ringer's solution or Plasma-Lyte, may be preferred over 0.9% saline to avoid hyperchloremic metabolic acidosis 4.

Isotonic Fluid Options

• Lactated Ringer's solution: a balanced crystalloid that may help mitigate hyperchloremia 4.
• Plasma-Lyte: a balanced crystalloid that may help maintain acid-base balance 4.
• 0.9% saline: an isotonic crystalloid that may exacerbate hyperchloremia and is generally not recommended as the first-line choice in patients with hyperchloremia 4.

Considerations for Fluid Management

• The goal of fluid resuscitation is to restore circulating fluid volume and optimize stroke volume, while avoiding fluid overload 3.
• Restrictive fluid administration, plus early vasopressor use, may reduce fluid balance and improve outcomes in septic patients 5.
• Human albumin solution may be considered in certain cases, such as hypoalbuminemia, to facilitate restrictive fluid therapy and improve hemodynamic stability 6, 5.