From the Guidelines
For resuscitation in a hypotensive patient, crystalloids are the recommended initial fluid of choice, with an initial administration of at least 30 mL/kg of IV crystalloid fluid given within the first 3 hours, as supported by the Surviving Sepsis Campaign guidelines 1. The choice of crystalloid can include 0.9% normal saline or balanced crystalloids like lactated Ringer's or Plasma-Lyte.
- Initial administration should be rapid, with reassessment of the patient's hemodynamic status after the initial bolus.
- Additional fluid boluses of 500-1000 mL may be given as needed, based on the patient's response to the initial fluid administration.
- Albumin 5% may be considered as a second-line option in patients requiring substantial crystalloid volumes or with hypoalbuminemia, as suggested by the guidelines 1.
- Blood products, particularly packed red blood cells, should be administered when hypotension is due to hemorrhage, aiming to maintain hemoglobin above 7-8 g/dL.
- Vasopressors, such as norepinephrine, should be initiated if hypotension persists despite adequate fluid resuscitation, with a recommended initial target mean arterial pressure of 65 mmHg 1. Crystalloids are preferred initially because they effectively expand intravascular volume, are readily available, and cost-effective, as noted in the guidelines 1.
- Balanced solutions may be superior to normal saline in critically ill patients as they cause less hyperchloremic metabolic acidosis and kidney injury with large-volume resuscitation. The guidelines recommend against the use of hydroxyethyl starches for fluid resuscitation of severe sepsis and septic shock 1, and suggest using crystalloids over gelatins when resuscitating patients with sepsis or septic shock 1.
From the FDA Drug Label
The solution is compatible with whole blood or packed red cells as well as the usual electrolyte and carbohydrate solutions intended for intravenous use Upon administration of ALBURX® 5, Albumin (Human) 5% solution, there is a rapid increase of the plasma volume about equal to the volume infused The initial dose for adults is 250 or 500 mL. For children, a dose of 22 to 33 mL per kilogram body weight is usually adequate
The recommended fluids for resuscitation in a patient with hypotension include:
- Albumin (Human) 5% solution (such as ALBURX® 5) 2
- Whole blood
- Packed red cells
- Electrolyte solutions
- Carbohydrate solutions It is essential to note that the choice of fluid and the rate of infusion should be guided by the patient's hemodynamic response and not by blood volume calculations or measurements. 2
From the Research
Resuscitation Fluids
The following are examples of resuscitation fluids:
- Crystalloids:
- Colloids:
Recommendations
According to the studies, crystalloids are the preferred solution for resuscitation in patients with severe sepsis and septic shock 4. Balanced crystalloids may improve patient-centered outcomes and should be considered as an alternative to normal saline, if available 4. Albumin or fresh frozen plasma (FFP) may be used as an alternative to crystalloids, but the evidence is uncertain 7.
Comparison of Fluids
Studies have compared the effects of different resuscitation fluids on patient outcomes:
- Normal saline (NS) versus Lactated Ringer's (LR): NS is not used for trauma resuscitation because of its potential for acidosis, but a study found that NS is a safe and viable alternative to LR in the trauma population 3.
- Crystalloids versus colloids: Crystalloids are less efficient than colloids at stabilizing resuscitation endpoints, but guidance on when to switch is urgently required 6. A systematic review found that using starches, dextrans, albumin or FFP, or gelatins versus crystalloids probably makes little or no difference to mortality 7.