From the Guidelines
Normal saline (0.9% sodium chloride) is recommended for fluid therapy in hypotensive bleeding trauma patients. According to the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1, fluid therapy using a 0.9% sodium chloride or balanced crystalloid solution should be initiated in these patients.
Key Considerations
- The use of hypotonic solutions such as Ringer’s lactate should be avoided in patients with severe head trauma 1.
- Colloids should be restricted due to their adverse effects on haemostasis 1.
- Balanced crystalloids may be advantageous over 0.9% sodium chloride due to their physiological or near-physiological concentrations of chloride, potentially reducing the risk of hyperchloraemic acidosis or kidney injury 1.
Administration Guidelines
- For adults requiring IV fluid resuscitation, an initial bolus of 500-1000 mL over 15-30 minutes is typically recommended, with reassessment after each bolus.
- For maintenance fluids in adults, 1.5-2.5 L per day (approximately 30 mL/kg/day) is standard, adjusted based on the patient's condition.
- In children, maintenance fluid rates follow the 4-2-1 rule: 4 mL/kg/hr for the first 10 kg, 2 mL/kg/hr for the next 10 kg, and 1 mL/kg/hr for each additional kg.
- For fluid resuscitation in children, 20 mL/kg boluses are recommended.
Important Considerations for Patient Care
- Normal saline contains 154 mEq/L of both sodium and chloride, making it isotonic with blood plasma.
- However, large volumes can cause hyperchloremic metabolic acidosis, so balanced crystalloids like lactated Ringer's may be preferred for large volume resuscitation.
- Normal saline should be used cautiously in patients with heart failure, kidney disease, or hyponatremia, and is contraindicated in patients with hypernatremia or severe metabolic acidosis.
- Fluid management should aim for a near-zero fluid and electrolyte balance to reduce the risk of complications and improve outcomes 1.
From the Research
Normal Saline Recommendations
- The use of normal saline solution (NSS) in critically ill patients has been compared to other fluid therapies in several studies 2, 3, 4, 5, 6.
- A randomized, controlled trial compared NSS to Ringer's acetate solution (RAS) in sepsis patients and found no statistically significant difference in major adverse kidney events or secondary outcomes 2.
- Another study compared lactated Ringer (LR) to Ringer solution (RS) in rats with severe hemorrhagic shock and found that RS led to improved outcomes compared to LR 3.
- A systematic review and meta-analysis of fluid resuscitation with balanced crystalloids versus normal saline in critically ill patients found no significant difference in mortality, but balanced crystalloids may reduce the risk of death in patients with non-traumatic brain injury 4.
- A randomized, controlled trial in pediatric sepsis patients found no difference in outcomes between NSS, Ringer lactate solution (RLS), and Sterofundin, but large doses of RLS were associated with reduced urinary neutrophil gelatinase-associated lipocalin (uNGAL) levels 5.
- An animal study found that lactated Ringer's solution was superior to normal saline in a model of massive hemorrhage and resuscitation 6.
Key Findings
- Normal saline solution may not be the optimal choice for fluid resuscitation in all patients, particularly those with severe hemorrhagic shock or non-traumatic brain injury 3, 4, 6.
- Balanced crystalloids, such as Ringer's acetate solution or lactated Ringer's solution, may be associated with improved outcomes in certain patient populations 2, 3, 4, 5, 6.
- Further research is needed to determine the optimal fluid therapy for specific patient populations and clinical scenarios 2, 3, 4, 5, 6.