In an adult with massive upper gastrointestinal bleeding causing hypovolemic shock, what fluids and resuscitation strategy should be used?

Fluid Resuscitation for Hypovolemic Shock Secondary to Massive UGIB

Use isotonic crystalloids as first-line fluid for resuscitation, with balanced crystalloids (such as lactated Ringer's solution) preferred over normal saline, and avoid routine use of colloids. 1

Fluid Type Selection

Crystalloids vs. Colloids

• Crystalloids should be used rather than colloids for initial volume expansion because colloids offer no mortality benefit, are significantly more expensive, and current evidence does not justify their routine use in clinical practice. 1, 2
• A Cochrane systematic review of 70 randomized controlled trials found no difference in mortality between critically ill patients who received colloids versus crystalloids for fluid resuscitation. 1
• One small randomized trial specifically in UGIB patients with hemorrhagic shock found no statistically significant difference in mortality between hypertonic saline dextran and Ringer lactate (RR 0.18,95% CI 0.02-1.41). 1

Balanced Crystalloids vs. Normal Saline

• Balanced crystalloids (such as lactated Ringer's solution) are preferred over normal saline as they reduce the risk of hyperchloremic metabolic acidosis and acute kidney injury. 2
• A large randomized trial in 15,802 critically ill patients found a small reduction in acute kidney injury (OR 0.91,95% CI 0.84-0.99) and possible small reduction in in-hospital mortality (10.3% vs. 11.1%; P=0.08) with balanced crystalloids versus saline. 1, 2
• Normal saline contains 154 mmol/L of both sodium and chloride, making it hyperchloremic compared to plasma, which can cause renal afferent arteriolar vasoconstriction and reduced glomerular filtration rate. 2
• If normal saline must be used, limit to 1-1.5 L maximum. 2

Resuscitation Strategy

Restrictive vs. Aggressive Approach

• The evidence is insufficient to make a firm recommendation for restrictive fluid resuscitation in UGIB, though animal models suggest early aggressive fluid resuscitation to normalize blood pressure may exacerbate blood loss, disrupt coagulation, and increase mortality. 1
• A Cochrane systematic review of 6 randomized trials in 2,128 patients with bleeding found that restrictive fluid resuscitation (delayed or smaller volume) was not inferior to aggressive resuscitation regarding mortality. 1
• The critical priority is to stop the bleeding while minimizing hemodynamic compromise, rather than achieving normal blood pressure targets. 1, 3

Volume and Administration Technique

• Fluid resuscitation should be initiated immediately in patients with UGIB and hemodynamic instability to restore end-organ perfusion and tissue oxygenation. 1
• Use fluid boluses of 250-1000 mL during initial resuscitation. 1
• The goals are to restore end-organ perfusion and tissue oxygenation while steps are taken to control bleeding. 1

Monitoring and Endpoints

Assessment of Response

• Monitor clinical measures of adequate tissue perfusion including capillary refill, skin temperature, pulse, blood pressure, conscious level, and urine output. 1
• Lactate clearance should be used to assess adequate response to resuscitation. 1, 2
• Sequential evaluation of dynamic variables including passive leg raise may be helpful in ventilated patients. 1
• Stop fluid resuscitation when no improvement in tissue perfusion occurs in response to volume loading. 3

Common Pitfalls and Caveats

• Avoid excessive fluid administration regardless of crystalloid type, as both lactated Ringer's and normal saline can cause volume overload. 2
• Development of pulmonary crepitations indicates fluid overload or impaired cardiac function. 3
• Do not delay definitive bleeding control (endoscopy, interventional radiology, or surgery) while pursuing aggressive fluid resuscitation. 1
• Frequent hemodynamic reassessment is essential, targeting tissue perfusion markers rather than fixed volumes. 2