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Key Words opments in the field. Summary: In this paper, we will review
Colloid · Crystalloid · Intensive care unit · Intravenous fluid · the impact of fluid overload on patient outcomes, define the
Resuscitation fluid challenge, describe the differences in static and dynam-
ic estimates of fluid responsiveness, and review the effect of
different types of fluid on patient outcome. Key Message:
Abstract Avoiding fluid overload by choosing the appropriate amount
Background: Intravenous fluids (IVF) are frequently utilized of fluids in patients who are fluid-responsive on one hand,
to restore intravascular volume in patients with distributive and treating IVF like other medications, on the other hand,
and hypovolemic shock. Although the benefits of the appro- are the major changes. Whenever clinicians decide to pre-
priate use of fluids in intensive care units (ICUs) and hospitals scribe IVF, they need to weigh the risks and benefits of giving
are well described, there is growing knowledge regarding fluid and also the advantages and side effects of each fluid
the potential risks of volume overload and its impact on or- type in order to optimize patient outcomes.
gan failure and mortality. To avoid volume overload and its © 2016 S. Karger AG, Basel
associated complications, strategies to identify fluid respon-
siveness are developed and utilized more often among ICU
patients. Apart from the amount of fluid utilized for resusci- Introduction
tation, the type of fluid used also impacts patient outcome.
Colloids and crystalloids are two types of fluids that are uti- Intravenous fluids (IVF) are routinely used in inten-
lized for resuscitation. The efficacy of each fluid type on the sive care units (ICUs) and hospitals in order to restore
expansion of intravascular volume on one hand and the po- effective blood volume and maintain organ perfusion
tential adverse effects of each individual fluid, on the other
hand, need to be considered when choosing the type of flu-
id for resuscitation. The negative impact of hydroxyethyl Contribution from the 1st Conference of the International Network
of Diagnosis and Management of Acid-Base, Electrolyte, and Fluid Al-
starch on kidney function, of albumin on the mortality of terations ‘Diagnosis and Management of Acid-Base, Electrolyte and
head trauma patients and chloride-rich crystalloids on mor- Fluid Alterations in Critically-Ill Patients’ held in Shanghai and Hang-
tality and kidney function, are only examples of new devel- zhou on January 14–16, 2016.
Two of the most commonly used measures of fluid re- Dynamic Measures of Fluid Responsiveness
sponsiveness have been CVP and pulmonary artery oc-
clusion pressure (cardiac filling pressures) as surrogates The poor performance of static measures of fluid re-
for the right and left ventricular end-diastolic volume sponsiveness created the need for the development of
(preload), respectively. Following the description of the other means to appreciate fluid responsiveness. Further
Frank-Starling curve in 1914 in an isolated heart-lung ca- investigations showed that among patients who are me-
nine model for investigation of cardiac output, CVPs chanically ventilated, heart-lung interactions could pro-
have been investigated and used as a measure of preload vide an opportunity for evaluation of fluid responsive-
[13]. Therefore, it was assumed that any increase in CVP, ness. When both ventricles are fluid-responsive, during
as an independent variable (x-axis in the Frank-Starling mechanical ventilation the stroke volume changes with
Cl = Chloride; Na = sodium.
a
Plasma-Lyte A has the same composition with the exception of a pH of 7.4. b Buffering
salt differs according to manufacturer, but may include sodium bicarbonate or sodium
chloride.
from infectious, inflammatory, and hemodynamic caus- ly recommends against the use of HES for resuscitation
es. Smaller studies have found disparate outcomes with in sepsis at this time.
respect to the renal safety of HES in sepsis [3, 14, 16, 33].
Recently, the Scandinavian Starch for Severe Sepsis/Sep- Crystalloids
tic Shock (6S) trial [15] sought to clarify the relationship The use of salt-based fluid resuscitation in critically ill
between HES and clinical outcomes in this patient popu- patients dates back to the cholera pandemic of the early
lation. This high-quality large clinical trial demonstrated 19th century. In the seminal work published in this field
a significant increase in the composite primary endpoint in 1832, Dr. Robert Lewins [35] described the successful
of death or dialysis dependence at 90 days in septic adults resuscitation of six cholera patients with a NaCl- and so-
randomized to a 6% 130/0.42 HES compared to individu- dium bicarbonate-based solution. In the two centuries
als randomized to Ringer’s acetate for fluid resuscitation that followed this letter, authors published many reports
(51 vs. 43%, respectively; p = 0.03). The composite end- which characterized the relative successes associated with
point was driven by the mortality aspect, as only 1% of the the use of various salt-based solutions for resuscitation
individuals who required any RRT during the follow-up [36]. These basic resuscitation solutions only limitedly re-
period remained dialysis-dependent at study day 90, but semble what we now refer to as ‘normal saline’, or 0.9%
secondary endpoints revealed a significantly greater need NaCl. This designation as ‘normal’ is an obvious mis-
for RRT overall in HES patients and fewer days alive with- nomer in that the solution of 154 mmol/l of sodium and
out RRT. Notably, a long-term follow-up analysis found 154 mmol/l of chloride is in no way analogous to the com-
that the statistically significant difference in crude and plex composition of the extracellular fluid. Its supra-
adjusted mortality between groups dissipated at 6 months physiologic chloride concentration (normal value 97–107
and 1 year of follow-up [12]. mmol/l), low pH, and lack of other essential extracellular
The results of the recent HES literature have been ions including potassium, bicarbonate, calcium, magne-
called into question because of the variability in the time sium, and phosphorous elicit a differential physiologic ef-
to and duration of HES administration, inconsistencies in fect when compared to resuscitation with more ‘balanced’
the algorithms for fluid use, presence or absence of he- salt solutions, such as lactated Ringer’s or Plasma-Lyte
modynamic instability, and inclusion of individuals with (table 1) [36, 37].
baseline renal dysfunction [34]. Regardless of these fac- Although the clinical debate about isotonic crystal-
tors, no convincing evidence exists to suggest the superi- loids is in its infancy, many physiologic mechanisms ex-
ority of HES over other fluid resuscitation strategies in plain the potentially detrimental consequences of the
hypovolemic critically ill patients, and the most recent routine use of unbalanced, chloride-rich crystalloids in
iteration of the Surviving Sepsis Campaign [1] specifical- the critically ill. Excess exogenous chloride administra-
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