From the Guidelines
For a shocked patient who is anxious, restless, confused, with a blood pressure of 80/40 mmHg, the most appropriate initial fluid would be option A, Ringer's lactate. This recommendation is based on the Surviving Sepsis Campaign guidelines, which suggest using crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and septic shock 1. The guidelines specifically recommend crystalloids over other types of fluids, such as hydroxyethyl starches, which are not recommended for fluid resuscitation of severe sepsis and septic shock 1. Ringer's lactate is a balanced crystalloid solution that provides electrolytes in physiologic concentrations and helps restore intravascular volume quickly. While normal saline could be used, it may cause hyperchloremic metabolic acidosis with large volumes. Blood products would be indicated if there is evidence of significant blood loss or severe anemia, but crystalloids are the first-line treatment for initial resuscitation while blood is being prepared. The recommended approach is to start with 1-2 L of Ringer's lactate given rapidly through large-bore IV access, reassess the patient's response, and then determine if blood products are needed based on clinical status and laboratory values 1. Key points to consider when choosing a fluid for resuscitation include:
- The type of shock: hypovolemic, cardiogenic, or distributive
- The patient's underlying medical conditions: such as heart failure or renal disease
- The patient's laboratory values: such as hemoglobin and hematocrit
- The patient's clinical response to initial fluid resuscitation: such as improvement in blood pressure and urine output. It is also important to note that the guidelines recommend against using hydroxyethyl starches for intravascular volume replacement in patients with sepsis or septic shock 1, and suggest using either balanced crystalloids or saline for fluid resuscitation of patients with sepsis or septic shock 1. Overall, the use of Ringer's lactate as the initial fluid for resuscitation in a shocked patient is supported by the latest guidelines and evidence, and is a key component of early goal-directed therapy for septic shock 1.
From the Research
Fluid Resuscitation for Hypovolemic Shock
- The patient's condition, characterized by anxiety, restlessness, confusion, and low blood pressure (80/40), suggests hypovolemic shock, which requires prompt fluid resuscitation.
- According to a study published in 2007 2, lactated Ringer's solution is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock, as it requires less volume and is associated with less hyperchloremic acidosis and dilutional coagulopathy.
- A systematic review and meta-analysis published in 2024 3 found that crystalloids, such as lactated Ringer's solution, have no significant mortality benefit over colloids, but are still widely used due to their availability and low cost.
- Another study published in 2022 4 compared the use of bicarbonated Ringer's solution and lactated Ringer's solution in patients with traumatic hepatic rupture and hemorrhagic shock, and found that the bicarbonated solution was associated with lower incidence of complications and shorter intensive care unit length of stay.
- A review article published in 2012 5 discussed the changes in resuscitation strategies for hemorrhagic shock, including permissive hypotension, minimal crystalloid resuscitation, and earlier blood transfusion, and highlighted the importance of institutional massive transfusion protocols in improving mortality and morbidity.
Recommended Fluid
- Based on the available evidence, lactated Ringer's solution (A) is a suitable choice for fluid resuscitation in this patient.
- Normal saline (B) may also be used, but it is associated with hyperchloremic acidosis and dilutional coagulopathy.
- Cross-matched blood (C) and non-cross-matched O negative blood (D) may be considered if the patient requires blood transfusion, but they are not the primary choice for initial fluid resuscitation.