What fluids are recommended for initial fluid resuscitation?

Initial Fluid Resuscitation: Crystalloids First

Use crystalloids as the initial resuscitation fluid, specifically balanced crystalloids (lactated Ringer's or Plasma-Lyte) over normal saline when available, and administer at least 30 mL/kg within the first 3 hours for septic patients. 1, 2, 3

Fluid Type Selection

First-Line: Balanced Crystalloids

• Balanced crystalloids (lactated Ringer's or Plasma-Lyte) are preferred over normal saline to reduce the risk of hyperchloremic metabolic acidosis and potentially improve survival 1, 3, 4
• In sepsis-induced hypotension specifically, lactated Ringer's solution was associated with lower mortality (12.2% vs 15.9%) and more hospital-free days compared to normal saline (adjusted hazard ratio 0.71; 95% CI 0.51-0.99) 4
• Balanced crystalloids reduce acute kidney injury risk more than normal saline and low molecular weight hydroxyethyl starch in septic patients 5

Alternative: Normal Saline

• Normal saline (0.9% sodium chloride) remains acceptable when balanced crystalloids are unavailable, though it carries higher risk of hyperchloremic metabolic acidosis 1, 3
• Normal saline is specifically preferred over balanced crystalloids in traumatic brain injury patients due to lower mortality risk 3, 5

Initial Dosing Protocol

Sepsis Patients

• Administer at least 30 mL/kg of crystalloid within the first 3 hours of sepsis recognition (strong recommendation, moderate quality evidence) 6, 2, 3
• This fixed volume (typically 2-3 liters in average adults) enables immediate resuscitation while obtaining more detailed hemodynamic assessments 6
• Many patients will require more than this initial bolus based on clinical response 6

Non-Septic Patients

• Administer fluid boluses of 250-1000 mL rapidly and repeatedly, reassessing hemodynamic status after each bolus 1, 2

Reassessment After Initial Bolus

Dynamic Over Static Measures

• Use dynamic measures of fluid responsiveness (pulse pressure variation, stroke volume variation, passive leg raise) rather than CVP alone, as static measures have poor predictive ability for fluid responsiveness 6, 2, 3
• Continue fluid administration as long as hemodynamic parameters continue to improve 2, 3

Clinical Parameters to Monitor

• Heart rate, blood pressure, respiratory rate, skin perfusion, capillary refill time 2
• Urine output (target >0.5 mL/kg/hr) 1, 2
• Mental status changes 2, 3
• Serum lactate levels (aim for 20% reduction if elevated) 6, 1

Role of Albumin

When to Consider Albumin

• Albumin may be considered in addition to crystalloids when patients require substantial amounts of crystalloids (weak recommendation, low quality evidence) 2
• The FDA label indicates albumin may be of value in sepsis or intensive care patients with hypoproteinemia and oncotic deficits 7
• In patients with cirrhosis, albumin is conditionally recommended over crystalloids 8

When NOT to Use Albumin

• Avoid albumin in traumatic brain injury patients—use isotonic saline instead due to increased mortality risk 8
• Albumin is not warranted for chronic nephrosis, chronic cirrhosis, or as a source of protein nutrition 7

Fluids to Avoid

Hydroxyethyl Starches

• Hydroxyethyl starches should NOT be used for fluid resuscitation in sepsis (strong recommendation, high quality evidence) due to increased mortality and acute kidney injury risk 2, 3, 5

Synthetic Colloids

• Synthetic colloids show no superiority to crystalloids and are significantly more expensive (albumin costs ~140 Euro/L, HES 25 Euro/L vs isotonic saline 1.5 Euro/L) 1
• Gelatins are less preferred than crystalloids (weak recommendation, low quality evidence) 2

Critical Pitfalls to Avoid

• Do not delay resuscitation—immediate fluid administration is required as delayed resuscitation increases mortality 2, 3
• Do not rely solely on CVP to guide fluid therapy, as it has poor predictive ability for fluid responsiveness 6, 2, 3
• Do not continue fluids indefinitely—stop when no improvement in tissue perfusion occurs, signs of fluid overload develop, or hemodynamic parameters stabilize 3
• Do not neglect reassessment—continuous clinical reassessment is essential to determine the need for additional fluids after the initial bolus 2