Volume Replacement in the Neonatal ICU:
Crystalloids and Colloids
K. G a r y M a g d e s i a n , DVM, Diplomate ACVIM,
John E. M a d i g a n , DVM, MS, Diplomate ACVIM
The perinatal foal has a higher body water content and turnover
rate than adult horses. Critically ill foals have even more complex
fluid requirements, dictated by hemodynamic alterations associ-
ated with systemic inflammatory response syndromes such as
sepsis or peripartum asphyxia syndrome. Understanding fluid
requirements and available fluid choices is an important part of
managing the ICU patient, to maximize fluid balance and oxygen
delivery to tissues. This paper reviews some of the unique
features of water balance in neonatal foals, fluid requirements for
replacement and maintenance needs, as well as available fluid
choices. Crystalloid and colloid solutions are discussed, empha-
sizing advantages and disadvantages of each.
Key Words: Crystalloids, colloids, fluids, volume support, neo-
natal foal
Copyright 2003, Elsevier Science (USA). All rights reserved.
eonatal foals have a larger volume of total body water,
N comprising approximately 75 to 83.3 % of body weight, as
compared to 60 to 70% of body weight in the adult horse. 1-5 In
addition, the extracellular fluid (ECF) compartment is rela-
tively larger in foals, occupying approximately 39.4 + 2.9 L/kg
of body weight, as opposed to approximately 22 to 29 I_/kg in
the adult. 6-~1Neonatal foals are expected to have a higher turn-
over of body water, as they have a higher metabolic rate than
adult horses. Foals have a relatively greater surface area and
reduced renal concentrating ability in the postpartum period as
compared to adult animals. 12,13
Normal urine output in neonatal foals is reported to be ap-
proximately 6 mIA~g/h. ~z This high output is related to a large
mtake of water, in the form of milk. Milk consists of approxi-
mately 89 to 90 % water, and healthy foals consume between 15
to 30% of body weight in milk per day. ~,~4 Reflecting this high
water intake and urine excretion, normal unne specific gravity
in newborn foals, after the first 24 hours postpartum, is usually
hyposthenuric (<1.008) and is reported to range from 1.001 to
1.027.i2,13
Fluid Replacement (Volume Resuscitation)
Fluid deficits can be replaced using crystalloids, colloids, or
both (please see discussions below). Briefly, crystalloids are
From the School of Veterinary Medicine, University of California, Davis,
Davis, CA, USA
Address reprint requests to Dr. K. Gary Magdeslan, One Shields Ave,
2108 Tupper Hall, School of Veterinary Medicine, Department of Medi-
cine and Epidemiology, University of California, Davis, Davis, CA 95616.
Copyright 2003, Elsevier Science (USA). All rights reserved.
1534-7516/03/0201-0001 $35.00/0
doi:l 0.1053/$1534-7516(03)00021-0
20
Diplomate ACVECC, and
solutions that contain electrolytes and/or glucose, while col-
loids contain large molecular weight particles, such as proteins,
which cannot freely cross capillary membranes. Recommenda-
tions for volume replacement in hypovolemic and dehydrated
foals include sequential boluses of 10 to 20 mL/kg of replace-
ment crystalloid over 10 to 30 minutes, x5,16Bolus administra-
tion of colloids, at a dose of 3 to 10 mL/kg may be used in
addition to or instead of crystalloid fluids. After completion of
each bolus, the foal's perfusion and hydration parameters
should be reassessed, to determine the need for further volume
replacement. This fluid volume resuscitation protocol is con-
servative, in order to avoid rapid alterations in central venous
pressure and subsequent edema formation. Critically ill foals often
have altered microvascular permeability and are at risk for edema
formation with only small changes in hydrostatic pressure.
Monitoring Replacement CrystaUoid Therapy
Assessment of fluid status should include physical examination
findings, including those that reflect intravascular volume sta-
tus. These perfusion parameters include mentation, heart rate,
extremity temperature, pulse quality, capillary refill time (Fig
1), jugular refill time, mucous membrane color, as well as urine
production. Hemodynamic monitoring, including measure-
ment of central venous pressure, arterial blood pressure, colloid
osmotic pressure, blood lactate, PrO2 and acid base status
should also be performed. Central venous pressure (CVP) is the
luminal blood pressure of the intrathoracic cranial (or caudal)
vena cava. It is regulated by central venous blood volume (ve-
nous return), venous tone, and cardiac output. CVP can be
measured using a plastic manometer with a three-way stopcock
fastened to extension tubing that is continuous with a central
venous catheter (Fig 2). Catheters which are 20 to 30 cm in
length (such as an Arrow intravenous catheter, Arrow Interna-
tional, Inc, Reading, PA), should be utilized for measurement of
CVP (Fig 3). Placement of the catheter within the cranial vena
cava can be confirmed through thoracic radiography (Fig 4).
Serial monitoring of CVP is useful in evaluating responses to
fluid boluses. Increase in CVP may be caused by volume over-
load, as might occur with excessive volume replacement or
right heart failure. There are a number of additional causes of
increased CVP, including increases in pleural or pericardial
pressures or false elevations as might occur with catheter oc-
clusion or the presence of air in the lines. Normal CVP in
neonatal foals is <10 to 12 cm of water (<9 mmHg). 17 CVP
values within the normal range do not rule out hypovolemia,
but overzealous fluid administration will result in increases in
CVP, and negative results are indicative of hypovolemia. Nor-
mal blood lactate in 24-hour foals is less than 2 to 2.5 mmol/L
(Ref 15, Magdesian, personal observations). Blood lactate ele-
Clinical Techniques in Equine Practice, Vol 2, No 1 (March), 2003: pp 20-30
 Fig 1. Prolonged capillary refill time may represent hypovolemia or hypotension.
vation occurs most commonly because of absolute or relative
tissue hypoxia, as with hypovolemia or cytopathic hypoxia,
respectively. However, it should be remembered that increases
in blood lactate concentration may also occur with hypermeta-
bolic states (as with sepsis), decreased clearance (liver failure),
inhibition of pyruvate dehydrogenase (as with thiamine defi-
ciency), and catecholamine surges or inflammatory mediators
associated with SIRS. As with CVP, serial measurement of lac-
tate, evaluating for trends and alterations, is probably more
important than one particular measurement. Arterial blood
pressure is discussed m the manuscript on hemodynamic mon-
itoring. Fluid balance should also be evaluated through moni-
toring of water intake and urine output in critically ill foals;
output is measured through means of a urinary catheter (Fig 5),
while input reflects both enteral and parenteral water intakes.
Milk is approximately 89 to 90 % water. Fluid input should be
approximately equal to urine output, in addition to estimations
of insensible losses and water retention for growth.
Hydration parameters, those that reflect interstitial volume
status rather than intravascular volume, include skin turgot,
tear film production (corneal quality), eye positioning (sunken
eyes reflecting dehydration), and mucous membrane texture.
Serial body weight measurements are very useful indicators of
total body water changes.
VOLUME REPLACEMENT IN THE NEONATAL IOU
Maintenance Fluid Requirements
Exact maintenance fluid requirements in the perinatal foal are
unknown. There are currently a number of different protocols
used to estimate fluid requirements in this age group of
horses. 16-1s One report recommends a maintenance fluid re-
quirement of 80 to 120 mL/kg/day, which translates to 3 to 5
mlJkg/h. Palmer estimates maintenance fluid requirements by
using the following calculations: 16
100 mL/kg per day for the first 10 kg of body weight
+ 50 mL/kg per day for the second 10 kg of body weight
+ 20-25 mL/kg per day for the remainder of body weight
Based on this formula, a 50-kg foal would require approxi-
mately 100 mldh of fluids for maintenance needs once rehy-
drated. Foals on either protocol should be monitored for ade-
quacy of fluid provision.
Even more elusive are the fluid requirements of the critically
ill foal. These likely vary considerably, with a high degree of
interindividual variability. A foal experiencing a systemic in-
flammatory response syndrome (SIRS) associated with diarrhea
will certainly require more daily fluid than one with perinatal
asphyxia syndrome and obtundation, recumbency, and com-
promised endothelial integrity.
21
 Fig 2. A water manometer and stopcock for measurement of central venous pressure.
Once dehydration and hypovolemia are corrected using re-
placement fluids (as described under 'Fluid Replacement'), the
author recommends initiating fluid plans for critically ill foals
using one of the methods described here for maintenance. Sub-
sequently, the foal should be monitored serially using clinical
examination findings, monitoring tools such as central venous
pressure, arterial blood pressure, urine output, and blood lac-
tate concentrations, as well as clinical pathologic markers such
as total protein, colloid osmotic pressure, and hematocrit or
packed cell volume. No one of these values will dictate fluid
needs alone, but rather the combination will monitor trends in
fluid balance and thus aid in directing fluid plans. For example,
a normal hematocrit or total protein should not necessarily
imply adequate hydration, because these may be independently
low for other reasons, including anemia and protein loss, re-
spectively. Other techniques useful in monitoring fluid balance
include measurements of body weight, serum albumin concen-
tration, BUN and creatinine, urine specific gravity, plasma os-
molarity, mixed venous oxygen saturation, thoracic radiogra-
phy, and echocardiography.
In addition to 'replacement' and 'maintenance' fluid require-
ments, on-going losses of fluid, as might occur with diarrhea or
reflux, should be accounted for in fluid plans.
22
Complications of Fluid Therapy
Complications of paremeral fluid therapy include overhydra-
uon and phlebitis. Volume overload and overhydration will be
reflected by: (1) significantly greater fluid input than output,
(2) increased CVP, (3) unexpected weight gain, (4) increased
skin turgor, (5) peripheral edema as manifested by ventral
edema or chemosis, and/or (6) increased respiratory rate or
deterioration of blood gases reflecting pulmonary edema. Ex-
cessive fluid administration should be detected before develop-
ment of edema, and this is where CVP and monitoring of input
versus output of fluid volume is useful.
Neonatal foals are often supplemented with dextrose in flu-
ids. Because neonatal foals with poor milk intakes are at risk for
hypoglycemia, fluids should initially provide 4 to 8 mg/kg/min
of dextrose.16 However, hyperglycemia should be avoided dur-
ing volume resuscitation because of potential complications,
such as intracellular acidosis and osmotic diuresis. Intensive
insulin therapy with tight regulation of blood glucose has re-
ceived recent attention in human critical care, and insulin may
exert antiinflammatory effects. 19,2 To prevent hyperglycemia,
blood glucose concentrations should be monitored frequently
in foals being supplemented with parenteral glucose in fluids.
MAGDESIAN AND MADIGAN
 Fig 3. A 20-30 cm triple lumen IV catheter is utilized for CVP measurement.
Crystalloids
Crystallolds are fluids containing small molecular weight mol-
ecules, such as electrolytes and glucose, that readily cross cap-
illary membranes. They fall into one of 2 categories, replace-
ment and maintenance fluids (Table 1). Replacement fluids are
isotonic to extracellular fluid and distribute accordingly. The
composition of replacement crystalloids resembles that of
plasma and the extracellular fluid. In contrast, maintenance
fluids are hypotonic relative to body fluids, and they distribute
among both the intraceflular and extracellular fluid compart-
ments. They contain less sodium and often more potassium
than replacement fluids.
I. Replacement Crystalloids
Lactated Ringer's Solution. Lactated Ringer's solution (LRS)
is a balanced, isotonic polyionic fluid. It is a good starting or
first line fluid in foals not suspected of being hyperkalemic, as it
contains 4 mEq of potassium per liter. The chloride content of
LRS (109 mEqFL) is relatively higher than that of normal equine
plasma, whereas the sodium concentration is on the lower limit
of physiologic concentrations (130 mEq/L). This may be a
slight disadvantage in treating hyperchloremic patients, as
compared to fluids with lower chloride concentrations, such as
Plasma-Lyte 148 or Normosol R (98 mEqFL). LRS contains
VOLUME REPLACEMENT IN THE NEONATAL ICU
lactate (28 mEq/L) as an alkalinizing agent, which is ultimately
metabolized to glucose (gluconeogenesis) or to carbon dioxide
and water, leading to a minor contribution of base. 21 Oxidation
to carbon dioxide and water is as follows:
NaC3HsO 3 + 302 --+ 2CO 2 + 2H20 + Na + + HCO3-
Gluconeogenesis consumes hydrogen ions and is also alkalin-
izing. 21 In patients with hepatic dysfunction or failure, the
lactate may not be metabolized normally. This may cause a
minor increase in plasma lactate concentrations, but will not
contribute directly to lactic acidosis because the form of lactate
in LRS is the sodium salt. LRS should not be administered
through the same lines as blood or plasma products, as these
contain citrate or other calcium antagonists, and LRS contains
calcium. Ideally, sodium bicarbonate should not be added di-
rectly to LRS, because of potential precipitation with calcium.
Hartmann's solution is very similar in composition to lactated
Ringer's solution. LRS is also available commercially as a 5%
dextrose solution.
Sodium chloride (0.9 % sodium chloride). Physiologic saline
(0.9 % sodium chloride) is an isotonic fluid containing only
sodium and chloride ions. Its lack of potassium allows it to be
used during hyperkalemic episodes, such as uroperitoneum,
acute renal failure, and hyperkalemic periodic paralysis crises.
However, its sodium to chloride ratio ( l : l ) is relatively greater
23
 Fig 4. A thoracic radiograph demonstrating proper placement of an IV catheter within the cranial vena cava.
than that of plasma, which has approximately 130 to 140
mEq/L sodium and 90 to 102 mEq/L of chloride. This relative
increase in chloride causes saline to effect a mild acidosis,
because of a relatively greater provision of strong anions as
compared to strong cations. Therefore, saline is useful in foals
with primary metabolic alkalosis, however, this is rarely en-
countered. Acidosis is common in critically ill foals, making
saline a less than optimal fluid choice in these patients.
Plasma-Lyte 148 or Normosol-R. Plasma-Lyte 148 (Baxter
Healthcare Corporation, Deerfield, IL) or Normosol-R (Abbott
Laboratories, North Chicago, IL) are polyionic crystalloids that
are similar to LRS with a few notable differences. They contain
magnesium, rather than calcium, and can therefore, be admin-
istered along with plasma or blood products containing citrate.
In addition, they contain acetate (27 mEq/L) and gluconate (23
mEq/L) as alkalinizers rather than lactate. =
Acetate:
NaC2H302 + 202 --+ CO2 + H20 + Na + + HCO3-
Gluconate:
2NaC6HnO7 + 1002 --->10CO 2 -~ 10H20 + 2Na + + 2HCO3-
24
Acetate is metabolized primarily in muscle, and this may be an
advantage for use in liver failure patients. 21 Another difference
between Plasma-Lyte or Normosol-R and LRS is the relative
sodium to chloride ratio, with the former fluids having 140
mEq/L sodium and 98 mEq/L chloride. This allows for a larger
strong ion difference (SID) in Plasma-lyte 148 (SID = 47 mEq/L
as opposed to approximately - 4 mEq/L in Hartmann's or LRS),
which may be advantageous in patients with metabolic acido-
sis. = The potassium content of Plasma-Lyte or Normosol is 5
m E @ . A variety of other Plasma-lyte solutions exist, including
Plasma-Lyte A, Plasma-Lyte R, and solutions containing dex-
trose (Baxter Healthcare Corporation), which have slight vari-
ations on Plasma-Lyte i48.
Isotomc bicarbonate. Isotonic bicarbonate solution can be
made by adding 150 mEq of sodium bicarbonate (150 mEq of
sodmm, 150 mEq of bicarbonate) to 1 liter of sterile water. This
solution is a good fluid choice for foals with inorganic (hy-
ponatremic, hyperchloremic) metabolic acidosis, as well as
those with hyperkalemia, such as those with uroabdomen.
Foals administered bicarbonate should be monitored for hypo-
kalemia, decreases in ionized calcium, metabolic alkalosis, and
MAGDESIAN AND MADIGAN
 Fig 5. Human infant feeding tubes can be utilized as urinary catheters in foals.
hypercapnia. Rapid administration of bicarbonate should be
avoided for these reasons, as well as to avoid the possible de-
velopment of paradoxical intracellular acidosis. Potentiation of
intracellular acidosis by rapid bicarbonate administration is an
equivocal phenomenon, which has been documented in
vitro. 23-26 A good rule of thumb is to administer half of the
estimated bicarbonate deficit (body weight in kg base defi-
cit X 0.4) over 1 to 2 hours @er replacement of fluid deficits,
and then to reassess the base deficit. Bicarbonate administration
should be performed with caution in foals with hypoventila-
tion, as it may further increase PaCO2.
II. Maintenance Crystalloids
Maintenance fluids are indicated in neonatal foals intolerant of
enteral feeding, as they provide an alternate source of free water
for distribution to the intracellular space in addition to the
ECF. They should be utilized only after the neonate is rehy-
drated with replacement fluids. Replacement crystalloids may
be inappropriate for use as maintenance fluids in foals, because
of the large sodium content, especially in foals intolerant of
enteral milk intake, aT Maintenance fluids can be developed
from replacement fluids through the administration of two-
thirds the desired fluid rate as 5% dextrose in water (D5W) and
one-third as replacement fluid. For example, if the fluid admin-
istration target is 150 mL per hour, then 50 mL of Plasma-Lyte
VOLUME REPLACEMENT IN THE NEONATAL ICU
148, and 100 mL of 5% dextrose in water would be adminis-
tered. The proportion of isotomc crystalloid and D5W could be
changed depending on electrolyte and hydration status. Alter-
natively, commercial maintenance fluids are available.
Plasma-Lyre 56 or Normosol M. Plasma-Lyre 56 (Baxter
Healthcare Corporation, Deerfield, IL) or Normosol M (Abbott
Laboratories, North Chicago, IL) are fluids that are hypoosmo-
lar relative to the ECF, with an osmolarity of approximately 111
m E @ . As expected, the sodium concentration is lower (40
m E @ ) , and potassium, the primary intracellular cation, is
higher (13 m E @ ) . Like their replacement counterparts, these
fluids contain magnesium rather than calcium. They contain
only acetate (16 mEq/L) as the alkalinizing salt. One difference
from the analogous replacement fluids is that the sodium to
chloride ratio is 1:1 in these maintenance fluids, which may
represent a slight disadvantage for acidotic patients with hyper-
chloremia.
Sodium chloride (0.45 %) and dextrose in water (2.5%). This
so-called "1/2 strength saline, 1/2 strength dextrose" crystalloid
is also a maintenance fluid. Like the above commercial fluids,
the sodium: chloride ratio is 1:1, however, the solution lacks
potassium or other electrolytes, as well as alkalinizing agents.
The advantage of this solution is that it can be used directly off
the shelf without having to add dextrose. This solution may be
ideal for maintenance of patients with hyperkalemia.
25
 Dextrose in water (5 %). Dextrose 5 % in water (D5W) is
isotonic (250 mOsm/L) as provided commercially. However,
because of metabolism of the dextrose, it is a source of free
water. Therefore, it should not be utilized in replacing fluid
deficits or hypovolemia. DSW also provides 170 kcal/L of di-
gestible energy and is devoid of electrolytes.
Colloid Replacement
Colloid osmotic pressure (COP) is the osmolarity generated by
large molecules that are unable to cross capillary membranes
freely. By increasing COP, they serve to promote fluid retention
within the intravascular compartment. In plasma, COP is be-
cause of plasma proteins, particularly albumin (60-80 % of
plasma COP). Albumin is the primary determinant of plasma
COP because of its relatively high concentration, small size,
and highly negative charge (Gibbs-Donnan effect).as The COP
generated by proteins is above that expected by the concentra-
tion in plasma. This is because of the Gibbs-Donnan effect,
which relates to the redistribution of ions induced by negatively
charged proteins in plasma; these protein 'anions' attract cat-
ions that would otherwise diffuse freely across the capillary.
Water is osmotically retained with these cations, thereby in-
creasing the amount of intravascular volume.
Colloids provide several advantages for volume resuscitation
of patients experiencing a systemic inflammatory response syn-
drome (SIRS). They are effective at replacing intravascular def-
icits rapidly. Smaller volumes and shorter infusion times are
required for volume resuscitation as compared to crystalloids.
Other indications for colloids include hypoproteinemia, espe-
cially if coupled to hypovolemia. The author attempts to main-
tain COP above 14 mmHg when restoring intravascular volume
in horses with acute hypoproteinemia. Judicious use of colloids
is important in foals with elevations in CVP, including those
with cardiac dysfunction. It should be pointed out that colloids
do not provide free water, and they should not be utilized as a
free water source for maintenance.
Monitoring Oncotic Pressure
Monitoring of colloid therapy is essentially the same as for
crystalloid therapy, with a few additions. Direct colloid osmotic
pressure and total protein or albumin concentrations should be
monitored serially during synthetic and plasma colloid admin-
istration, respectively. In addition, clotting times and platelet
counts should be monitored in patients receiving synthetic
colloids. Oncotic pressure in normal adult horses ranges be-
tween 20 and 30 mmHg. 29-33 The reported colloid osmotic
pressure in normal neonatal foals is 18.8 -+ 1.9 mmHg (plasma
COP interval = 15.0-22.6 mmHg, 95% CI). 31 Both direct and
indirect methods can be used to measure COP. Direct colloid
osmometry is performed by means of a colloid osmometer, such
as the Wescor 4420 colloid osmometer (Wescor Inc, Logan
UT) 34'35 Direct measurements are preferred to indirect calcula-
tions in critically ill patients. 32 Indirect calculations that use
total protein or albumin/globulin concentrations, such as the
Landis-Pappenheirner equation, are good estimates of direct
COP in healthy horses and foals, but may not be as accurate in
clinically ill patients with altered A/G ratios and altered pH or
electrolyte compositions. 32,33,36 Indirect measurements do not
detect changes in COP produced by synthetic colloids, and
direct osmometry is therefore the only means of monitoring
26
and directing synthetic colloid therapy from an oncotic pres-
sure standpoint. 29,32
Crystalloids Versus Colloids
The ideal fluid for volume resuscitation in the neonatal equine
ICU is unknown. There are a number of conflicting reports in
human critical care medicine causing debate whether crystal-
loids or colloids should be used during volume resuscita-
tion. 37-44 The use of crystalloids versus colloids in pediatric
human patients is also controversial. 43.44 Current philosophy
recognizes the advantages of both crystalloids and colloids, and
a 'Mending' of the two may be the optimal choice. Insensible
and isotonic fluid losses should be replaced with crystalloids.
Isotonic crystalloids distribute among the extracellular fluid
space, including the intravascular and interstitial spaces, ac-
cording to their respective volumes. Thus, crystalloids allow for
greater interstitial rehydration compared to colloids, which
may be a disadvantage when edema is present. Expansion of
blood volume with crystalloids results in a decrease in plasma
protein concentrations, and thus COP. Colloids allow for main-
tenance of plasma oncotic pressure. Colloids are confined to the
intravascular space, assuming an intact endothelial barrier, and
are therefore indicated in hypovolemic shock. 45 Sepsis and
other SIRS conditions may reduce the capillary reflection coef-
ficient by compromising capillary integrity, thereby reducing
the effectiveness of colloids. Marked increases in microvascular
permeability, as is associated with some forms of acute respira-
tory distress syndromes and early burn injuries, are a corltrain-
dication to the administration of colloids, as they will extrava-
sate and promote edema formation. A deterioration of clinical
or blood gas parameters post colloid administration may repre-
sent such a state and warrants discontinuation of colloid ther-
apy.
The concurrent use of both crystalloid and colloid solutions
obviates the need for large volume administration of crystal-
loids, minimizes the risk of interstitial edema, and may restore
blood volume more rapidly than crystalloids alone, while still
allowing for interstitial reexpansion. 46-48 A 'blending' of crys-
talloids and colloids should be considered whenever colloids
are not contraindicated.
Biologic Colloid Solutions
Plasma. Plasma is an excellent colloid for the critically ill
neonate (Fig 6). The administration of large doses of plasma
(20-40 mL/kg) is not cost prohibitive for the neonatal foal,
thereby allowing a significant contribution to COP by plasma.
In addition to albumin, plasma provides immunoglobulins, fi-
bronectin, clotting factors, antithrombin, and other constitu-
ents that may benefit patients with SIRS. The COP of plasma
products is approximately 20 to 25 mmHg. In addition to pro-
viding oncotic pressure, albumin is an important carrier pro-
tein for hormones, drugs, and toxins, and therefore has impor-
tant functions besides generating oncotic pressure. Both stable
and labile clotting factors are present in fresh (administered to
the patient within 6 hours of collection) and fresh frozen (fro-
zen within 6 hours of collection without being refrigerated;
stored for less than 1 year). Stored plasma (frozen for longer
than 1 year) contains only functional stable factors, including
factors II, VII, IX, and X. Refrigeration destroys labile coagula-
tion factors (V, VIII, and vWf). Platelet-rich plasma (fresh) is
MAGDESIAN AND MADIGAN
 Fig 6. Commercial equine plasma is an excellent colloid for use in neonatal foals.
the only source capable of replacing platelets. Because the COP
of plasma is equivalent to the oncotic pressure of normal
horses, and because 60% or more of albumin may redistribute
extravascularly, foals with significant hypoproteinemia may re-
quire the use of synthetic colloids for additional oncotic sup-
port. Foals receiving plasma transfusions should be monitored
for signs of hypersensitivity and transfusion reactions, includ-
ing pyrexia, tachycardia, tachypnea, muscle tremors, colic, ur-
ticaria, and signs of anaphylaxis. Plasma should be adminis-
tered through a blood administration set containing filtration
devices.
Whole blood. Whole blood transfusions may be indicated as
the colloid of choice in cases of hemorrhagic shock, while
washed dam erythrocytes are ideal for foals with neonatal iso-
erythrolysis. Complications associated with blood transfusions
include reactions due to incompatible red blood cells, as well as
those associated with transfer of leukocytes. Citrate toxicity
and hypocalcemia are other potential side effects. Donor ani-
mals should be screened for blood-borne diseases. Red blood
cells do not exert oncotic pressure, and therefore packed red
blood cells do not offer an advantage over whole blood from a
colloid standpoint. Whole blood should not be administered
through the same lines as calcium containing fluids, and fluids
without calcium such as Normosol-R (Abbott Laboratories) or
VOLUME REPLACEMENT IN THE NEONATAL ICU
Plasma-Lyte 148 (Baxter Healthcare Corporation) should be
used instead.
Synthetic Colloids
Hydroxyethyl starch (Hetastarch). Hetastarch is the most
commonly used synthetic colloid in horses (Fig 7).29,3.49 It is a
modified branched-chain glucose polymer originating from
amylopectin. It is available as a 6% aqueous solution in saline
(Abbott Laboratories) or lactated electrolyte solution (Hex-
tend@, Abbott Laboratories). The COP of hetastarch is approx-
imately 30 mmHg, making it a more cost-effective colloid than
plasma. The primary side effect associated with hetastarch ad-
ministration is an induction of coagulopathies associated with
reductions in coagulation factor VIII and yon Willebrand's fac-
tor. Platelet counts and function may also be altered. Hypersen-
sitivity reactions are also rarely reported. Unlike dextrans,
hetastarch does not interfere with blood typing or cross match-
ing.
There are no studies evaluating hetastarch in foals. Recom-
mended doses of hetastarch based on studies conducted in
adult horses are up to 8 to 10 ml/kg/day. 29,3,5 Foals in need of
rapid volume support may be bolused 3-5 ml/kg hetastarch in
addition to crystalloids. In addition to bolus administration,
27
 Fig 7. Hetastarch and dextrans are examples of synthetic colloids.

hetastarch can be used as a slow infusion (0.5-1 mL/kg/h, up to drome, thrombocytopenia, or other hypocoagulable states
10 mldkg/day) for colloid support in hypooncotic animals. should not be administered hetastarch.
Until further research is available, larger doses of hetastarch Pentastarch. Pentastarch (DuPont Critical Care, McGaw,
should be used with caution. Foals with von Willebrand's syn- IL) is a narrow-range, medium molecular weight derivative of

28 MAGDESIAN AND MADIGAN

 TABLE 1. Electrolyte Composition and Osmolarity of Various Replacement and Maintenance Fluids
Crystalloid Sodium Potassium Chloride Calcium Magnesium Osmolarity Organic

Replacement
LRS 130 4 109 3 0 272-273 28 lactate
Saline (0.9%) 154 0 154 0 0 308 0
Ringers soln 147-148 4 156 4.5 0 310 0
Plasma-Lyte148 140 5 98 0 3 294 27 acetate
23 gluconate
Normosol R 140 5 98 0 3 294 27 acetate
23 gluconate
Maintenance
Plasma-Lyte 56 40 13 40 0 3 111 16
Normosol M 40 13 40 0 3 110 16
0.45% saline/2.5% dextrose 77 0 77 0 0 280 0
5% dextrose 0 0 0 0 0 252-253 0

hetastarch. The COP of pentastarch is 40 mmHg. It is more
homogenous than hetastarch in terms of size, excluding very
small or large molecules. Advantages over hetastarch include
fewer side effects on the coagulation and reticuloendothelial
(RE) systems. 51,52 Because of its narrower molecular weight
range, pentastarch may be indicated for use in patients with
increased capillary permeability associated with SIRS. Pen-
tastarch shows promise for use in capillary leak syndromes, as it
should be retained within the circulation to a greater extent
than hetastarch, and it may aid in plugging leaky capillaries. 53
Fractions of colloids with molecular weights between 100 and
1000 kd may represent the ideal size for sealing of widened
endothelial cell gap junctions. Smaller MW molecules ,nay po-
tentiate third space accumulation of fluid, while larger mole-
cules could potentially interfere with sealing.54 Another advan-
tage of pentastarch is its potential for larger volume expansion
as compared to hetastarch.
Dextrans. Dextrans are long glucose polymers produced
from sucrose by the bacterium Leuconostoc mesenteroides (Fig
7). Dextran 70 is available as a 6% solution (6% Gentran 70,
Baxter Healthcare Corp) with a COP near 60 mmHg. The
higher colloid oncotic pressure of dextran 70 is misleading, as
many of the smaller molecules are rapidly eliminated, leaving a
comparable number of larger molecules as hetastarch.
Dextran 70 is associated with a higher rate of complications
than hetastarch. Allergic reactions and coagulation distur-
bances appear to be more common. 51 Dextrans also mterfere
with crossmatching of blood products due to adherence to red
cell membranes and clumping of erythrocytes. For these rea-
sons, the use of hetastarch is currently recommended over
dextrans for use in neonatal foals.
Hemoglobin-based products. Oxyglobin (Biopure, Cam-
bridge, MA) contains polymerized bovine hemoglobin and is
labeled for increasing oxygen carrying capacity in dogs. Oxy-
globin also provides a colloid effect (approximately 42 mmHg).
The shelf life of the product is 3 years at room temperature.
Disadvantages of Oxygobhn include discoloration of mucous
membranes and body fluids. It also interferes with several bio-
chemical analyses and eliminates the ability to monitor hemat-
ocrit or erythrocyte count. Scavenging of nitric oxide by Oxy-
globin may result in regional tissue vasoconstriction, a
disadvantage that may counteract some of its oxygen carrying
benefits. Its ability to provide oxygen carrying capacity to
plasma is an advantage in low blood flow and ischemic tissues.
Oxyglobin has been used in neonatal foals with neonatal
isoerythrolysis and anemia. Anecdotal reports suggest that a
dose of 5 to 7.5 mL/kg may be of benefit to foals with neonatal
isoerythrolysis (NI) while awaiting blood transfusion. One case
report described the administration of 22 mI_/kg of polymerized
hemoglobin to a foal with NI. 55 In that foal, the Oxyglobin
treatment maintained oxygen delivery for up to 18 hours before
washed red blood cells were administered.
Conclusion
There is little documentation supporting specific parenteral
fluid management practices in neonatal foals. Current recom-
mendations are based on a combination of evidence, experi-
ence, and extrapolation from adult horses and neonates of other
species. Available fluids include crystalloids, both replacement
and maintenance selections, as well as colloids. Understanding
the physiologic needs of the critical neonate is the best means of
dictating fluid therapy, and continual reassessment of fluid
balance, using clinical and clinicopathologic markers as well as
monitoring tools, is of utmost importance in managing the ICU
patient.
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MAGDESIAN AND MADIGAN