What are the indications for using specific intravenous (IV) fluids?

From the Guidelines

Intravenous (IV) fluids should be selected based on the patient's specific clinical condition, electrolyte status, and fluid needs, with balanced crystalloids like Ringer’s lactate being the preferred choice for most patients, as recommended by the most recent guidelines 1.

Key Considerations for IV Fluid Selection

• The patient's underlying condition, such as trauma, burns, or surgical status, should guide the choice of IV fluid.
• Electrolyte status and acid-base balance should be considered when selecting an IV fluid.
• Hemodynamic needs, such as hypovolemic shock or metabolic alkalosis, should also be taken into account.
• Frequent reassessment is necessary to adjust therapy as the clinical situation evolves.

Specific IV Fluids and Their Uses

• Normal saline (0.9% NaCl) is appropriate for mild to moderate dehydration, hypovolemic shock, and metabolic alkalosis due to its isotonic nature.
• Lactated Ringer's solution is suitable for trauma, burns, and surgical patients as it closely mimics plasma electrolyte composition.
• Dextrose 5% in water (D5W) is useful for providing free water in hypernatremia or when calories are needed, while becoming hypotonic once the dextrose is metabolized.
• Hypertonic saline (3% or 5% NaCl) is reserved for severe hyponatremia or increased intracranial pressure.
• Colloids like albumin are indicated for hypovolemic patients who need plasma expansion, particularly those with hypoalbuminemia, burns, or liver disease.

Recent Guidelines and Recommendations

• The most recent guidelines recommend avoiding the use of 0.9% saline due to the risk of salt and fluid overload 1.
• Balanced crystalloids like Ringer’s lactate are preferred for intraoperative fluid management 1.
• Postoperative IV fluids should be discontinued at the latest during day 1, and patients should be encouraged to drink when fully recovered and offered an oral diet within 4 hours after abdominal/pelvic surgery 1.

From the FDA Drug Label

2 DOSAGE & ADMINISTRATION Dosage for Acute Use in Plasma Volume Expansion 6% Hetastarch in 0.9% Sodium Chloride Injection is administered by intravenous infusion only.

The amount usually administered is 500 to 1000 mL. Doses of more than 1500 mL per day for the typical 70 kg patient (approximately 20 mL per kg of body weight) are usually not required.

• Hydroxyethyl starch (IV) is used for:
  • Plasma volume expansion in adults, with a typical dose of 500 to 1000 mL.
  • Leukapheresis, with a dose of 250 to 700 mL.
• Albumin (IV) is used for:
  • Emergency treatment of hypovolemic shock, with the total dose not exceeding 2 g per kg body weight.
  • Burn therapy, to maintain plasma colloid osmotic pressure beyond 24 hours after sustaining thermal injury.
  • Hypoproteinemia with or without edema, during major surgery, sepsis, or intensive care.
  • Adult Respiratory Distress Syndrome (ARDS), with a diuretic.
  • Cardiopulmonary bypass, to achieve a hematocrit of 20% and a plasma albumin concentration of 2.5 g per 100 mL.
  • Acute liver failure, to support the colloid osmotic pressure of the plasma and bind excess plasma bilirubin.
  • Neonatal hemolytic disease, to bind free bilirubin prior to exchange transfusion, with a dosage of 1 g/kg body weight 2 3

From the Research

Fluid Resuscitation Guidelines

The choice of intravenous (IV) fluid for resuscitation depends on various factors, including the patient's condition, disease state, and clinical setting. The following are some guidelines for using specific IV fluids:

• Crystalloids:
  • Preferred for most patients, especially those with sepsis or traumatic brain injury 4, 5
  • Balanced crystalloids, such as Plasma-Lyte 148, are recommended over normal saline due to their lower chloride content and potential to reduce metabolic acidosis 6
• Colloids:
  • May be used in patients with severe bleeding or hypovolemic shock, but their use is controversial in patients with sepsis 4, 7
  • Hydroxyethyl starch (HES) solutions, such as HES 130/0.4, may be used as an alternative to crystalloids, but their use is associated with an increased risk of acute kidney injury (AKI) and renal replacement therapy (RRT) 5, 8
• Albumin:
  • May be used in patients with severe hypoalbuminemia or liver disease, but its use is not recommended as a first-line treatment for fluid resuscitation 4
• Hypertonic Saline:
  • May be used in patients with traumatic brain injury or severe hypovolemic shock, but its use is not recommended as a first-line treatment for fluid resuscitation 7

Patient-Specific Considerations

The choice of IV fluid may also depend on the patient's specific condition, such as:

• Sepsis: Crystalloids are preferred, but colloids may be used in patients with severe sepsis or septic shock 4, 8
• Traumatic Brain Injury: Hypertonic saline or colloids may be used to help manage intracranial pressure and improve outcomes 7
• Bleeding or Hypovolemic Shock: Colloids or crystalloids may be used to help restore blood volume and improve hemodynamics 4, 7

Clinical Setting Considerations

The choice of IV fluid may also depend on the clinical setting, such as:

• Intensive Care Unit (ICU): Crystalloids are often preferred due to their ease of use and lower risk of complications 4, 6
• Emergency Department: Crystalloids or colloids may be used, depending on the patient's condition and the availability of resources 4, 8