What are the recommended fluid choices for different clinical scenarios in patients requiring fluid resuscitation?

From the Guidelines

For fluid resuscitation, crystalloids are the recommended initial fluid of choice in most clinical scenarios, including sepsis and septic shock, with an initial volume of 20-30 mL/kg. The choice of fluid varies by clinical scenario, with balanced crystalloids (like Lactated Ringer's or Plasma-Lyte) preferred for most situations, including sepsis, trauma, and general resuscitation, as they cause less metabolic derangement than normal saline 1. Normal saline (0.9% NaCl) remains appropriate for patients with metabolic alkalosis, traumatic brain injury, or hyponatremia, typically given at similar volumes. For hemorrhagic shock, crystalloids are used initially while preparing blood products, followed by balanced transfusion with packed red blood cells, fresh frozen plasma, and platelets in a 1:1:1 ratio. Albumin (5% or 25%) may benefit patients with cirrhosis and spontaneous bacterial peritonitis at 1.5 g/kg on day 1 followed by 1 g/kg on day 3. Hypertonic saline (3% NaCl) is indicated for severe symptomatic hyponatremia or elevated intracranial pressure, administered at 2-3 mL/kg over 10-20 minutes.

Some key points to consider when choosing a fluid for resuscitation include:

• The type of shock or fluid loss (e.g. hypovolemic, septic, hemorrhagic)
• The patient's underlying medical conditions (e.g. cirrhosis, traumatic brain injury)
• The patient's electrolyte and acid-base status
• The need for ongoing fluid resuscitation and monitoring of patient response

Avoid synthetic colloids like hydroxyethyl starch due to increased risk of kidney injury and mortality 1. Fluid choice should be reassessed frequently based on patient response, with careful monitoring of vital signs, urine output, electrolytes, and acid-base status to guide ongoing therapy. The most recent and highest quality study, published in 2020, supports the use of restrictive volume of resuscitation fluid (less than 20 mL/kg) and balanced crystalloid solution (e.g. Ringer’s lactate) in pediatric patients with septic shock 1.

From the Research

Fluid Resuscitation in Different Clinical Scenarios

The choice of fluid for resuscitation depends on the clinical scenario and the patient's condition. The following are some recommended fluid choices for different clinical scenarios:

• Burn Patients: Hypertonic lactate saline (HLS) solutions have been used in some burn centers to maintain plasma volume without infusing larger fluid volumes 2.
• Nonsurgical Critically Ill Patients: There is no definitive evidence about the best fluid for resuscitation, and buffered solutions versus isotonic saline are being compared in a Cochrane review 3.
• Neurocritical Care Patients: Maintaining euvolemia with crystalloids seems to be the recommended fluid resuscitation, and buffered crystalloids have been shown to reduce hyperchloremia in patients with subarachnoid hemorrhage without causing hyponatremia or hypo-osmolality 4.
• Severe Head Injury Patients: Hypertonic saline is superior to lactated Ringer's solution for resuscitation, as it requires fewer interventions, has fewer complications, and results in shorter ICU stay times 5.
• Critically Ill Patients: Colloids compared to crystalloids do not reduce the risk of death, and their use is not justified outside the context of randomised controlled trials due to their higher cost 6.

Key Considerations

When choosing a fluid for resuscitation, the following factors should be considered:

• The type and severity of the patient's condition
• The patient's fluid and electrolyte status
• The potential risks and benefits of different fluid types
• The availability and cost of different fluids

Fluid Types

The following are some common types of fluids used for resuscitation:

• Crystalloids (e.g. lactated Ringer's solution, isotonic saline)
• Colloids (e.g. albumin, hydroxyethylstarch, modified gelatin, dextran)
• Hypertonic solutions (e.g. hypertonic saline, hypertonic lactate saline)