What are the guidelines for fluid therapy in various diseases?

Fluid Therapy in Various Diseases

General Principles Across All Conditions

For critically ill patients requiring fluid resuscitation, use crystalloids as the first-line fluid of choice, with balanced crystalloids preferred over normal saline to reduce complications and length of stay. 1, 2

Initial Resuscitation Strategy

• Administer at least 30 mL/kg of crystalloid solution within the first 3 hours for patients with sepsis-induced hypoperfusion or septic shock 2, 3
• Use isotonic crystalloid solutions (osmolarity 280-310 mOsm/L) such as 0.9% NaCl, Plasma-Lyte, or Isofundine for initial volume expansion 1
• Infuse at 15-20 mL/kg/hour during the first hour in adults without cardiac compromise 1
• Continue fluid administration using a fluid challenge technique as long as hemodynamic factors continue to improve 2

Fluid Type Selection by Clinical Context

Balanced crystalloids should be favored over normal saline in most critically ill patients to reduce the risk of hyperchloremic metabolic acidosis and acute kidney injury 1, 4

• In general critically ill patients: use balanced crystalloids rather than isotonic saline (conditional recommendation, low certainty) 4
• In sepsis: use balanced crystalloids rather than isotonic saline (conditional recommendation, low certainty) 4
• In acute kidney injury: use balanced crystalloids rather than isotonic saline (conditional recommendation, very low certainty) 4

Important exception: In traumatic brain injury, use isotonic saline rather than balanced crystalloids to avoid potential complications from hypotonic effects 4

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Disease-Specific Fluid Management

Sepsis and Septic Shock

Crystalloids are the fluid of choice with at least 30 mL/kg administered within 3 hours, followed by vasopressor initiation if hypotension persists 2, 3

• Use norepinephrine as first-choice vasopressor if mean arterial pressure remains below 65 mmHg despite adequate fluid resuscitation 2, 3
• Reassess hemodynamic status frequently using clinical examination: heart rate, blood pressure, respiratory rate, urine output, mental status, and peripheral perfusion 2
• Dynamic measures of fluid responsiveness are preferred over static measures like central venous pressure when available 2
• Monitor for signs of fluid overload including pulmonary crackles, increased jugular venous pressure, and worsening respiratory function 1, 3

Diabetic Ketoacidosis (DKA) and Hyperglycemic Hyperosmolar State (HHS)

Initial fluid therapy with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour is directed toward intravascular volume expansion and restoration of renal perfusion 1

• After the first hour, switch to 0.45% NaCl at 4-14 mL/kg/hour if corrected serum sodium is normal or elevated 1
• Continue 0.9% NaCl at similar rate if corrected serum sodium is low 1
• Add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO4) once renal function is assured 1
• Typical total body deficits: 6-9 liters water, 7-10 mEq/kg sodium, 3-5 mEq/kg chloride, 3-5 mEq/kg potassium 1

Pediatric Acute and Critical Illness

Use isotonic maintenance fluids in acutely and critically ill children to reduce the risk of hyponatremia (strong recommendation, Grade A) 1

• Balanced solutions should be used when prescribing intravenous maintenance fluid therapy to slightly reduce length of stay 1
• Avoid lactate buffer solutions in severe liver dysfunction to prevent lactic acidosis 1
• Provide glucose in sufficient amounts guided by at least daily blood glucose monitoring to prevent hypoglycemia 1
• Add appropriate potassium based on clinical status and regular monitoring to avoid hypokalemia 1

Restrict maintenance fluid volume in children at risk of increased ADH secretion:

• Restrict to 65-80% of Holliday-Segar formula volume to avoid fluid overload and hyponatremia 1
• In heart failure, renal failure, or hepatic failure: restrict to 50-60% of Holliday-Segar formula 1
• Reassess fluid balance and clinical status at least daily, with regular electrolyte monitoring 1

Burns

After 24 hours post-burn, use 25% albumin (Plasbumin-25) to maintain plasma albumin concentration at 2.5 ± 0.5 g/100 mL 1, 5

• Target plasma oncotic pressure of 20 mmHg (equivalent to total plasma protein 5.2 g/100 mL) 1
• During first 24 hours: administer large volumes of crystalloids to restore depleted extracellular fluid volume 5
• Duration of albumin therapy depends on protein loss from burned areas and urine 1
• Initiate oral or parenteral amino acid feeding as albumin should not be considered a nutrition source 1

Cirrhosis and Ascites

Use albumin rather than crystalloids in patients with cirrhosis (conditional recommendation, very low certainty) 4

• Albumin infusion may be required to support blood volume after removal of ascitic fluid to prevent hypovolemic shock 5
• This represents one of the few conditions where albumin is preferred over crystalloids 4

Hypoproteinemia

Unless the underlying pathology can be corrected, albumin administration is purely symptomatic 5

• Usual daily dose: 50-75 g for adults, 25 g for children 5
• Administer at rate not exceeding 2 mL/minute in hypoproteinemic patients with normal blood volumes to prevent circulatory embarrassment and pulmonary edema 5
• Patients with severe hypoproteinemia who continue to lose albumin may require larger quantities 5

Cardiopulmonary Bypass

Adjust albumin and crystalloid pump prime to achieve hematocrit of 20% and plasma albumin concentration of 2.5 g/100 mL 5

• Preoperative blood dilution using albumin and crystalloid is safe and well-tolerated with modern pumps 5

Adult Respiratory Distress Syndrome (ARDS)

When clinical signs show hypoproteinemia with fluid volume overload, use 25% albumin together with a diuretic 5

• Use crystalloids rather than albumin for general volume expansion in acute respiratory failure (conditional recommendation, very low certainty) 4

Traumatic Brain Injury

Use isotonic saline rather than albumin (conditional recommendation, very low certainty) 4

Use isotonic saline rather than balanced crystalloids (conditional recommendation, very low certainty) 4

• Hypertonic saline is effective in mannitol-refractory intracranial hypertension 6
• Hypotonic solutions are absolutely contraindicated in impending cerebral edema 6

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Monitoring and De-escalation

Fluid Overload Prevention

Avoid fluid overload and cumulative positive fluid balance to prevent prolonged mechanical ventilation and increased length of stay 1

• Calculate total daily fluid intake including: IV fluids, blood products, all IV medications, line flush solutions, and enteral intake (excluding replacement fluids) 1
• Monitor for clinical signs: increased jugular venous pressure, pulmonary crackles/rales, peripheral edema 1
• Reduce fluid rate if signs of overload present 1

Reassessment Criteria

Following initial resuscitation, additional fluids must be guided by frequent reassessment of hemodynamic status 2

• Assess improvement in mental status, urine output, and peripheral perfusion 2, 3
• Monitor vital signs continuously including heart rate, blood pressure, respiratory rate, oxygen saturation 3
• Reassess at least daily in terms of fluid balance, clinical status, and electrolytes (especially sodium) 1

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Critical Pitfalls to Avoid

• Never use hydroxyethyl starches for intravascular volume replacement due to increased risk of acute kidney injury and mortality (strong recommendation, high quality evidence) 2
• Avoid hypotonic solutions in patients with or at risk of cerebral edema 6
• Do not use lactate-buffered solutions in severe liver dysfunction 1
• Avoid excessive glucose in critically ill children; monitor blood glucose at least daily 1
• Do not administer albumin too rapidly in hypoproteinemic patients (maximum 2 mL/minute) to prevent circulatory overload 5
• Recognize that clinical indicators like heart rate, blood pressure, and urine output may not detect early hypovolemia, and edema is a late sign of fluid overload 7