What are the recommended types of infusion for fluid resuscitation?

Recommended Types of Infusion for Fluid Resuscitation

Crystalloids are the recommended first-choice fluids for initial resuscitation and subsequent intravascular volume replacement in patients requiring fluid resuscitation. 1, 2

Primary Fluid Choices

• Crystalloids should be used as the initial fluid of choice in the resuscitation of patients with hypovolemia, sepsis, and septic shock 1, 2, 3
• Either balanced crystalloids (such as Ringer's lactate) or normal saline (0.9% NaCl) can be used, though balanced solutions may be preferred due to concerns about hyperchloremic metabolic acidosis with normal saline 1, 3
• The most recent evidence suggests that initial fluid resuscitation with lactated Ringer's solution compared to 0.9% saline may be associated with improved survival in patients with sepsis-induced hypotension 4
• An initial fluid challenge of at least 30 mL/kg of crystalloids is recommended within the first 3 hours for patients with sepsis-induced tissue hypoperfusion 1, 2, 3

Secondary Fluid Options

• Albumin may be considered in addition to crystalloids for initial resuscitation and subsequent intravascular volume replacement when patients require substantial amounts of crystalloids 1, 2, 3
• Hydroxyethyl starches should NOT be used for intravascular volume replacement due to increased risk of mortality and renal replacement therapy, particularly in septic patients 1, 2, 5
• Crystalloids are recommended over gelatins when resuscitating patients 1
• Dextrans are used less often due to problems with anaphylaxis and potential increased risk of renal failure 6

Administration Technique

• A fluid challenge technique should be applied where fluid administration is continued as long as hemodynamic factors continue to improve 1, 2
• Dynamic variables of fluid responsiveness (e.g., change in pulse pressure, stroke volume variation) are preferred over static variables (e.g., central venous pressure) to guide ongoing fluid administration 1, 2
• More rapid administration and greater amounts of fluid may be needed in some patients based on clinical response 1, 3

Special Considerations

• For patients with gastrointestinal bleeding, crystalloids are also recommended as the initial fluid of choice 1
• In trauma patients, albumin appears to be associated with increased mortality and should be avoided 1
• In neonatal and pediatric hypovolemic shock, rapid fluid resuscitation in excess of 40 ml/kg in the first hour may be associated with improved survival 1
• For patients with low ejection fraction, consider smaller fluid boluses with frequent reassessment rather than the standard 30 mL/kg 2

Monitoring Response to Fluid Resuscitation

• Assess for signs of adequate tissue perfusion, including improved mental status, urine output, and peripheral perfusion 2, 7
• Monitor for signs of fluid overload, such as pulmonary crackles, increased jugular venous pressure, and worsening respiratory function 2, 7
• Guiding resuscitation to normalize lactate levels in patients with elevated lactate as a marker of tissue hypoperfusion is recommended 2

Common Pitfalls

• Delayed fluid resuscitation increases mortality; immediate fluid resuscitation is required in shock states 3
• Reliance on static measures like central venous pressure alone to guide fluid therapy is no longer recommended due to poor predictive ability for fluid responsiveness 2, 3
• Fluid overresuscitation should be avoided as it can delay organ recovery, prolong ICU stay, and increase mortality 2, 8
• The standard 30 mL/kg fluid recommendation may need modification based on individual patient characteristics, particularly cardiac function 2