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 recommend crystalloids, such as Ringer's lactate, for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock, due to their ability to restore intravascular volume and maintain electrolyte balance. Some key points to consider in the management of this patient include:
- Initial fluid resuscitation should begin with at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 1.
- Additional fluids should be guided by frequent reassessment of hemodynamic status, including clinical examination and evaluation of available physiologic variables 1.
- Dynamic variables, such as pulse pressure variation, should be used to predict fluid responsiveness where available 1.
- The initial target mean arterial pressure (MAP) should be 65 mm Hg in patients with septic shock requiring vasopressors 1. Overall, the use of Ringer's lactate as the initial fluid in this scenario is supported by the guidelines and is consistent with current best practices in the management of septic shock.
From the Research
Fluid Resuscitation for Shocked Patient
The patient is experiencing shock, anxiety, restlessness, confusion, and has a blood pressure of 80/40. The appropriate fluid for resuscitation in this scenario is crucial.
- The study 2 compared the hemodynamic effects of hypertonic saline 5% and lactated Ringer's solutions in patients with hemorrhagic shock, and found that both solutions can improve hemodynamic status, but lactated Ringer's is more potent in improving tissue oxygenation.
- Another study 3 found that initial fluid resuscitation with lactated Ringer's solution, compared with 0.9% saline, might be associated with improved survival in patients with sepsis-induced hypotension.
- A study 4 compared the use of hypertonic salt solution with Ringer's lactate as an initial resuscitation fluid for the treatment of hemorrhagic shock, and found that hypertonic saline increases cardiac output with less net fluid and decreases pulmonary vascular resistance.
- The study 5 compared the effects of lactated Ringer's solution, hypertonic saline dextran, and HBOC-201 on tissue oxygen tension levels in selected tissue beds after hemorrhagic shock, and found that there were no significant differences in measured liver or muscle PO2 values after resuscitation with any of the three solutions.
- Another study 6 compared the effects of Plasma-lyte A, lactated Ringer's, and normal saline on acid-base status and intestine injury in the initial treatment of hemorrhagic shock, and found that Plasma-lyte A is better at correcting the acid-base balance and improving intestine injury during hemorrhagic shock than normal saline and lactated Ringer's.
Recommended Fluid
Based on the studies, the recommended fluid for resuscitation in this scenario is:
- Lactated Ringer's solution (A) is a suitable option, as it can improve hemodynamic status and tissue oxygenation 2, 3.
- However, the patient's condition and the underlying cause of shock should be considered when choosing the most appropriate fluid.
Other Options
- Saline 1000 ml (B) may not be the best option, as it can lead to hyperchloremic acidosis and may not provide the same level of tissue oxygenation as lactated Ringer's solution 3, 6.
- Crossed matched blood (C) and non-cross matched O negative blood (D) may be considered if the patient is experiencing significant blood loss, but they are not typically used as initial resuscitation fluids.