What is the best IV fluid for resuscitation in a patient with diarrhea due to abnormal lithium (lithium) levels?

From the Guidelines

Normal saline (0.9% sodium chloride) is the preferred IV fluid for resuscitation in patients with diarrhea due to abnormal lithium levels. The initial approach should focus on volume replacement with normal saline at a rate determined by the patient's clinical status, typically starting with a 1-2 liter bolus followed by maintenance fluids. Normal saline is particularly beneficial in this scenario because it helps correct volume depletion while promoting lithium excretion through the kidneys. Lithium is exclusively eliminated by the kidneys, and saline diuresis enhances its clearance. According to the Surviving Sepsis Campaign guidelines 1, crystalloids are recommended as the initial fluid of choice for resuscitation, and normal saline is a commonly used crystalloid. Although there are concerns about the use of saline as the main IV fluid, such as hyperchloraemic acidosis or increased incidence of kidney injury 1, the benefits of normal saline in promoting lithium excretion outweigh these risks in this specific scenario. During resuscitation, closely monitor the patient's vital signs, urine output, electrolytes (particularly sodium), and serial lithium levels. Potassium supplementation may be necessary if hypokalemia develops from diarrhea. Once the patient is hemodynamically stable and lithium levels are decreasing, the fluid rate can be adjusted based on clinical response. In severe cases with very high lithium levels or kidney injury, hemodialysis may be required, but normal saline remains the initial fluid of choice for most patients.

Some key points to consider when using normal saline for resuscitation in this scenario include:

• Starting with a 1-2 liter bolus to correct volume depletion
• Monitoring urine output and adjusting the fluid rate accordingly
• Avoiding lactated Ringer's solution due to its lower sodium content
• Closely monitoring electrolytes, particularly sodium and potassium
• Considering potassium supplementation if hypokalemia develops
• Adjusting the fluid rate based on clinical response and serial lithium levels.

It is essential to prioritize the patient's clinical status and adjust the treatment plan accordingly, as the goal is to minimize morbidity, mortality, and improve quality of life. The most recent and highest quality study 1 suggests that balanced crystalloids may be advantageous in some scenarios, but in the context of lithium toxicity, normal saline remains the preferred choice due to its ability to promote lithium excretion.

From the FDA Drug Label

Decreased tolerance to lithium has been reported to ensue from protracted sweating or diarrhea and, if such occur, supplemental fluid and salt should be administered under careful medical supervision and lithium intake reduced or suspended until the condition is resolved

• The best IV fluid for resuscitation in a patient with diarrhea due to abnormal lithium levels is not explicitly stated in the drug label.
• However, it is mentioned that supplemental fluid and salt should be administered under careful medical supervision.
• The choice of IV fluid should be based on the patient's individual needs, taking into account the loss of fluids and electrolytes due to diarrhea.
• Isotonic fluids, such as 0.9% sodium chloride or lactated Ringer's solution, may be considered for resuscitation, but the specific choice of fluid is not specified in the drug label 2.

From the Research

Diarrhea due to Abnormal Lithium Levels

• The best IV fluid for resuscitation in a patient with diarrhea due to abnormal lithium levels is not directly addressed in the provided studies.
• However, study 3 suggests that balanced crystalloid solutions, such as Ringer's lactate, may be a better choice than 0.9% saline for treating acute diarrhea and severe dehydration in children, as they likely result in a slight reduction of the time in hospital and reduce the risk of hypokalaemia.
• Study 4 recommends against using sodium chloride infusion for treating lithium intoxication, as it can lead to hypernatraemia.
• Study 5 provides guidance on fluid resuscitation in patients with hypertrophic pyloric stenosis, but its relevance to lithium intoxication is limited.
• Studies 6 and 7 discuss the treatment of lithium poisoning using hemodialysis, but do not address the choice of IV fluid for resuscitation.

Key Considerations

• The choice of IV fluid for resuscitation in a patient with diarrhea due to abnormal lithium levels should be based on the patient's individual needs and the severity of their dehydration and electrolyte imbalances.
• Balanced crystalloid solutions, such as Ringer's lactate, may be a better choice than 0.9% saline, but more research is needed to confirm this.
• Sodium chloride infusion should be used with caution, as it can lead to hypernatraemia 4.
• Hemodialysis may be necessary in severe cases of lithium poisoning, but the choice of IV fluid for resuscitation is not directly addressed in the provided studies 6, 7.