What fluids do you recommend for fluid resuscitation?

Fluid Recommendations for Resuscitation

Crystalloids are the recommended first-choice fluid for initial resuscitation and subsequent intravascular volume replacement in patients requiring fluid resuscitation. 1

Initial Fluid Selection

Primary Recommendation

• Use isotonic crystalloids (such as normal saline or balanced crystalloids) as the first-line fluid for resuscitation 1
• Initial fluid challenge should be 10-20 ml/kg in children 1 and at least 30 ml/kg in adults with sepsis 1
• Continue fluid administration as long as hemodynamic parameters improve 1

Specific Crystalloid Options

• Either balanced crystalloids (e.g., Ringer's lactate) or normal saline can be used 1
• Some evidence suggests balanced crystalloids may be preferable to saline in certain situations due to concerns about hyperchloremic metabolic acidosis with large volumes of normal saline 1, 2

When to Consider Colloids

Colloids should generally be considered second-line options after crystalloids, with specific indications:

• Albumin may be added to crystalloids when patients require substantial amounts of fluid replacement 1
• Synthetic colloids may be considered when large fluid volumes are required (e.g., severe sepsis) due to their longer intravascular duration 1
• In pediatric patients with severe Dengue shock syndrome (pulse pressure <10 mmHg), colloids may be beneficial 1

Fluids to Avoid

• Hydroxyethyl starches (HES) should NOT be used for intravascular volume replacement in patients with sepsis or septic shock 1
• Evidence shows HES is associated with increased mortality and renal replacement therapy requirements 1, 2
• Crystalloids are preferred over gelatins for resuscitation 1

Special Considerations

Pediatric Patients

• Isotonic saline is the first-choice fluid for initial resuscitation in neonates and children with hypovolemia 1
• Initial fluid volume should be 10-20 ml/kg with repeated doses based on clinical response 1
• For children with traumatic hemorrhagic shock, introduce blood products after 20-40 ml/kg of crystalloid if ongoing volume replacement is needed 3

Septic Patients

• Apply a fluid challenge technique where administration continues as long as hemodynamic factors improve 1
• Consider adding vasopressors if fluid resuscitation cannot restore tissue perfusion 1
• For patients requiring vasopressors, norepinephrine is the first-choice agent 1

Burn Patients

• Traditional approach uses crystalloid resuscitation with empirical formulas (Parkland for adults, Shriner for children) 4
• Some burn centers use hypertonic lactate saline solutions to maintain plasma volume with smaller fluid volumes 5

Common Pitfalls and Caveats

1. Excessive fluid administration: Overzealous fluid resuscitation can lead to fluid overload, which is associated with worse outcomes 2

2. Relying solely on static parameters: Fluid administration should be guided by dynamic parameters (e.g., change in pulse pressure, stroke volume variation) rather than static variables alone 1

3. Delayed blood product administration: In traumatic hemorrhage, delay in transitioning from crystalloids to blood products can worsen outcomes 3

4. Cost considerations: Colloids are significantly more expensive than crystalloids (albumin ~140 Euro/L vs. isotonic saline ~1.5 Euro/L) 1 without proven mortality benefit 6

5. Monitoring inadequacy: Relying solely on vital signs and urinary output may be inadequate for detecting malperfusion 4