Fkuid Selection Dynamed

DynaMed 10/2/19 19'46
Fluid selection for IV fluid resuscitation
Updated 2018 Oct 04 11:13:00 AM: balanced crystalloids may slightly reduce major adverse kidney events compared to
saline in noncritically ill adults (N Engl J Med 2018 Mar 1) view update Show more updates
Topic Editor
Constantine Manthous, MD
Recommendations Editor
Esther Jolanda van Zuuren, MD
Deputy Editor
Terence K. Trow, MD, FACP, FCCP
Related Summaries:
Dehydration and hypovolemia in adults
Dehydration and hypovolemia in infants and children
Rehydration therapy in children
Hemorrhagic shock
Sepsis treatment in adults
Sepsis treatment in children
Overview:
fluid resuscitation aims to restore and maintain intravascular volume for adequate tissue perfusion as part of complex
hemodynamic resuscitation strategies in patients showing signs of decompensation
broadly categorized as crystalloids or colloids based on molecular content
treated and used like any other intravenous drug
professional organizations generally agree on recommended fluids for IV fluid resuscitation
crystalloid solutions are recommended for initial management (SCCM Strong recommendation, Moderate-quality evidence;
ABC-T Grade 1B; KDIGO Level 2, Grade B)
hydroxyethyl starches are not recommended due to risk of acute kidney injury (SCCM Strong recommendation, High-quality
evidence )
some organizations suggest albumin 4%-5% in additional to crystalloids in patients with severe sepsis or septic shock
requiring substantial amounts of crystalloids (SCCM Weak recommendation, Low-quality evidence )
crystalloid solutions contain ions freely permeable across capillary membrane with fluid tonicity determined by sodium and
chloride concentrations
classified as chloride-rich or balanced solutions
saline (sodium chloride) most commonly used crystalloid solution
balanced salt solutions approximate physiological solutions
hypertonic and isotonic crystalloid solutions may have similar mortality, but hypertonic solutions may have higher rates of
adverse events
colloids solutions contain large molecular weight molecules largely unable to cross capillary membranes suspended in carrier
solution
human albumin (4%-5% in saline) considered reference colloid solution
albumin may not reduce mortality compared to crystalloids in most patients with critical illness, but may increase
mortality in burn patients
albumin might reduce mortality compared to crystalloids in adults with sepsis or septic shock
hydroxyethyl starch solutions are most commonly used semisynthetic colloids
hydroxyethyl starch does not decrease mortality and increases risk of renal replacement therapy compared to other
fluid resuscitation agents in patients requiring fluid resuscitation
fluid resuscitation with hydroxyethyl starch increases risk of renal replacement therapy and might increase mortality
http://web.a.ebscohost.com.wdg.biblio.udg.mx:2048/dynamed/…NpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d#AN=906227&db=dme Página 1 de 21
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compared to crystalloid or albumin in patients with sepsis

comparing crystalloids vs. colloids
hydroxyethyl starch may increase mortality and risk of renal replacement therapy compared to crystalloids
balanced saline and albumin may reduce mortality compared to other fluids in patients with sepsis
hemoglobin-based blood substitutes may increase mortality and risk of myocardial infarction in patients with stroke, trauma, or
having surgery
General Information
IV fluidtherapy in hospitalized patients is indicated for 4 reasons(3)
resuscitation (the focus of this topic) - urgent delivery for restoration of circulation after intravascular volume loss due to
bleeding, plasma loss, or excessive external fluid and electrolyte loss (such as from gastrointestinal tract), or severe
internal losses (such as from redistribution)
routine maintenance - to meet normal fluid or electrolyte needs in patients unable to otherwise meet needs
replacement - nonurgent replacement of fluids lost from intravascular or other compartments to correct existing or
ongoing deficits
redistribution - compensation for significant internal fluid shifts
fluid loss resulting in signs of decompensation require urgent IV fluid resuscitation(3)
signs include
tachycardia
peripheral hypoperfusion and delayed capillary refill
decrease in systolic blood pressure
oliguria
tachypnea
reduced level of consciousness, agitation, confusion
physiologic responses to intravascular volume loss include
sympathetic responses prioritizes blood flow to vital organs
heart rate usually increases and peripheral vasoconstriction leads to increased diastolic blood pressure
systolic blood pressure decreases significantly when > 30%-40% of intravascular volume lost
hypoperfusion leads to organ system dysfunction and general tissue hypoperfusion leads to acidosis and increased
oxygen extraction
fluidtherapy is 1 factor in complex hemodynamic resuscitation strategies(1, 2, 3)
aims to restore and maintain intravascular volume for adequate tissue perfusion
adjunctive therapies for improving circulation should be considered early
avoid fluid overload
effects of fluid administration on end-organ function should be considered in conjunction with effects on intravascular
volume
ability of individual patients to compensate for fluid loss varies with age, comorbidities, and other factors
resuscitation fluids broadly categorized as crystalloids or colloids(1, 2, 3)
crystalloid solutions contain ions freely permeable across capillary membrane with fluid tonicity determined by sodium
and chloride concentrations (for example, normal saline)
colloid solutions contain large molecular weight molecules largely unable to cross capillary membranes suspended in
carrier solution (for example, albumin)
resuscitation fluids should be treated and used like any other intravenous drug(1, 2, 3)
consider correct compound, dose, and possible side effects for each patient and indication
all fluids can contribute to interstitial edema, especially in patients with inflammatory conditions such as sepsis
volume of resuscitation fluids needed varies considerably and frequent reassessment is needed for optimal administration
Physiology:
classic compartment model includes intracellular fluid compartment and extracellular fluid compartment made up of interstitial
and intravascular fluids(1, 3)
flux between fluids and electrolytes in compartments is continual, but homeostatic physiological mechanisms maintain
fluid balance
appropriate fluidtherapy considers factors affecting fluid distribution and balance across compartments
Starling principle built off observation that capillaries and postcapillary venules act as semipermeable membranes absorbing
fluids from interstitial space(1)
Starling principle suggests fluid filters from capillaries to interstitial space under dominant hydrostatic pressure gradient
and is absorbed into capillaries under dominant colloid osmotic pressure gradient
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recent evidence has changed understanding of this fluid dynamic

nonfenestrated capillaries filter fluid to interstitial space, but absorption of fluid does not occur through venules and
instead enters circulation primarily as lymph
endothelial glycocalyx layer (membrane bound glycoproteins and proteoglycan on luminal side of endothelial cells) is
key determinant of membrane permeability
review of Starling equation and glycocalyx model can be found in Br J Anaesth 2012 Mar;108(3):384, commentary can be
found in Br J Anaesth 2012 Jun;108(6):1035
Recommendations from Professional Organizations
guideline recommendations are largely based on expert consensus opinion or low-quality evidence(1)
synthesis of included guidelines
guidelines recommend crystalloid solutions for initial management for patients requiring IV fluid resuscitation and
recommend against using hydroxyethyl starches due to risk of acute kidney injury
recommendations for use of other colloid solutions are limited, but some suggest albumin 4%-5% may be considered in
patients with severe sepsis or septic shock requiring substantial amounts of crystalloids
National Institute for Heath and Care Excellence (NICE) recommendations on IV fluidtherapy in adults in
hospital
in patients requiring IV fluid resuscitation, use crystalloid solution (sodium concentration 130-154 mmol/L) with 500 mL
bolus in < 15 minutes
do not use tetrastarch for fluid resuscitation
in patients with severe sepsis, consider human albumin 4%-5% solution for fluid resuscitation
Reference - NICE 2013 Dec:CG174 PDF
British Consensus Guidelines on Intravenous FluidTherapy for Adult Surgical Patients (GIFTASUP) 2012
recommendations for fluid resuscitation
if crystalloid resuscitation indicated, use balanced salt solutions (Ringer lactate/acetate or Hartmann solution) instead of
0.9% saline to reduce risk of hypercholeremic acidosis unless patient has hypochloremia (GIFTASUP Level 1b)
do not use solutions that are sources of free water for maintenance such as 4% dextrose/0.18% saline and 5% dextrose
for resuscitation unless patient has condition with significant free water deficit (such as diabetes insipidus) due to risk of
hyponatremia (GIFTASUP Level 1b)
in patients with hypovolemia (GIFTASUP Level 1b)
if due to blood loss, use either balanced crystalloid or suitable colloid solution until packed red blood cells available
if due to severe inflammation (infection, peritonitis, pancreatitis, or burns), use balanced crystalloid or suitable
colloid
carefully administer solution to normalize hemodynamic parameters, but minimize overload
ability to excrete excess sodium and water is compromised
patients are at risk of severe interstitial edema
hyperoncotic state may be initiated by administration of large colloid volumes without sufficient free water (such
as 5% dextrose)
in patients with severe sepsis, do not use higher molecular weight (MW) hydroxyethyl starch (hetastarch and pentastarch
MW ≥ 200 kilodaltons) due to increased risk of acute kidney injury (GIFTASUP Level 1b)
in patients with rhabdomyolysis at risk of developing secondary acute kidney injury
use isotonic crystalloid solution for aggressive fluid resuscitation to correct hypovolemia (GIFTASUP Level 5)
insufficient evidence to recommend specific crystalloid solution
Reference - GIFTASUP 2012 PDF
Surviving Sepsis Campaign international guidelines on for management of sepsis and septic shock
recommendations on fluid resuscitation
crystalloids recommended as initial fluid for resuscitation as well as subsequent intravascular volume replacement (SCCM
Strong recommendation, Moderate-quality evidence )
if sepsis-induced hypoperfusion, give ≥ 30 mL/kg IV within first 3 hours (SCCM Strong recommendation, Low-quality
evidence)
dynamic instead of static variables suggested to predict fluid responsiveness (SCCM Weak recommendation, Low-
quality evidence)
consider either balanced crystalloids or saline for fluid resuscitation (SCCM Weak recommendation, Low-quality evidence)
do not use hydroxyethyl starches (HES) for intravascular volume replacement (SCCM Strong recommendation, High-
quality evidence )
consider albumin in addition to crystalloids for fluid resuscitation when patients require substantial amounts of
crystalloids (SCCM Weak recomendation, Low-quality evidence )
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consider crystalloids over gelatins for resuscitation (SCCM Weak recommendation, Low-quality evidence )
Reference - Intensive Care Med 2017 Mar;43(3):304
Task Force for Advanced Bleeding Care in Trauma (ABC-T) guidelines on initial management of bleeding and
coagulopathy following major trauma
in patients without brain injury, maintain target systolic blood pressure at 80-90 mm Hg until major bleeding is stopped
(ABC-T Grade 1C)
in patients with severe traumatic brain injury (Glasgow Coma Scale ≤ 8), maintain mean arterial pressure ≥ 80 mm Hg
(ABC-T Grade 1C)
use restricted volume replacement to attain target blood pressure until bleeding can be controlled (ABC-T Grade 1B)
fluidtherapy
isotonic crystalloid infusion recommended for initial treatment of hypotensive bleeding trauma patient (ABC-T Grade
1A)
avoid excessive use of 0.9% saline (ABC-T Grade 2C), as 0.9% saline may increase risk of a hyperchloremic nongap
acidosis and kidney injury compared to balanced electrolyte solutions
in patients with severe head trauma, avoid hypotonic solutions (such as Ringer lactate) (ABC-T Grade 1C)
consider restricting colloid use due to adverse effects on hemostasis (ABC-T Grade 2C)
Reference - Crit Care 2016 Apr 12;20:100 full-text
2010 joint Statement on Prevention and Management of Acute Renal Failure in ICU Patients recommendations
for fluid resuscitation
joint statement by American Thoracic Society, European Respiratory Society, European Society of Intensive Care
Medicine, Society of Critical Care Medicine, Société de Réanimation de langue Française
fluid resuscitation with crystalloid solutions is as safe and effective as with hypooncotic colloid solutions (4% albumin and
gelatins)
hyperoncotic colloid solutions (20%-25% albumin, hydroxyethylstarches, or dextrans) not recommended for routine fluid
resuscitation due to risk of renal dysfunction
Reference - Am J Respir Crit Care Med 2010 May 15;181(10):1128
Kidney Disease: Improving Global Outcomes (KDIGO) 2012 clinical practice guideline for acute kidney injury
recommendations for fluid resuscitation
in patients with or at risk for acute kidney injury and without hemorrhagic shock, isotonic crystalloids suggested over
colloids (albumin or starches) for initial fluid resuscitation (KDIGO Level 2, Grade B)
Reference - KDIGO clinical practice guideline for acute kidney injury (KDIGO (2011) 2012 Mar PDF)
American Society of Anesthesiologists recommends against routinely administering colloid (dextrans, hydroxyethyl starches,
albumin) for volume resuscitation without appropriate indications (Choosing Wisely 2013 Oct 12)
Crystalloids
Crystalloids as first choice for resuscitation:

crystalloid solutions are recommended as first-line therapy by
National Clinical Guideline Centre (United Kingdom) 2013 guidelines on IV fluidtherapy in adults in hospital
Surviving Sepsis Campaign (SCCM Strong recommendation, Moderate-quality evidence )
Task Force for Advanced Bleeding Care in Trauma (ABC-T) guidelines on initial management of bleeding and
coagulopathy following major trauma (ABC-T Grade 1B)
2010 Statement on Prevention and Management of Acute Renal Failure in ICU Patients recommendations for fluid
resuscitation
Kidney Disease: Improving Global Outcomes (KDIGO) 2012 clinical practice guideline for acute kidney injury
Types of crystalloids:
Type and Composition of Crystalloid Resuscitation Fluids(1, 2, 3):
Solution Osmolarity pH Sodium Chloride Potassium Calcium Magnesium Lactate Acetate

Reference Human 291 7.35- 135-145 94-111 94-111 2.2-2.6 0.8-1 1-2 mmol/L 0 mmol/L
plasma mOsm/L 7.45 mmol/L mmol/L mmol/L mmol/L mmol/L (plus 23-27
mmol/L
biocarbonate)
Chloride Normal 308 4.5- 154 154 0 mmol/L 0 0 mmol/L 0 mmol/L 0 mmol/L
rich saline mOsm/L 7 mmol/L mmol/L mmol/L
0.9%
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Ringer 310 6 147 155 4 mmol/L 4 0 mmol/L 0 mmol/L 0 mmol/L

solution mOsm/L mmol/L mmol/L mmol/L
Balanced Ringer 274 6-7.5 130 109 4 mmol/L 1.4 0 mmol/L 28 mmol/L 0 mmol/L
lactate mOsm/L mmol/L mmol/L mmol/L
Ringer 276 6-8 130 112 5 mmol/L 1 1 mmol/L 0 mmol/L 27

acetate mOsm/L mmol/L mmol/L mmol/L mmol/L
Hartmann 278 5-7 131 111 5 mmol/L 2 0 mmol/L 29 mmol/L 0 mmol/L

mOsm/L mmol/L mmol/L mmol/L
Plasma- 294 4-8 140 98 5 mmol/L 0 3 mmol/L 0 mmol/L 27

Lyte mOsm/L mmol/L mmol/L mmol/L mmol/L
with 23
mmol/L
gluconate
crystalloid solutions contain ions freely permeable across capillary membrane with fluid tonicity determined by sodium and
chloride concentrations(1, 2, 3)
saline (sodium chloride) most commonly used crystalloid solution(1)
normal (0.9%) saline is isotonic with equal concentrations of sodium and chloride(1, 2, 3)
chloride-rich solution with strong ion difference of zero
large volumes may cause hyperchloremic metabolic acidosis
lowers strong ion difference in serum and can cause an acid/base imbalance
may impair immune system and cause kidney dysfunction
infusion of large amounts of sodium may cause postresuscitation interstitial sodium and water retention
balanced salt solutions approximate physiological solutions(1)
relatively hypotonic with lower concentration of sodium compared to extracellular fluid
alternative anion (lactate, acetate, gluconate, or malate) used due to instability of bicarbonate-containing solutions in
plastic
large volumes may cause hyerlactatemia, metabolic alkalosis, hypotonicity, and cardiotoxicity
combining solutions containing calcium with red-cell transfusions may cause microthrombi
balanced salt solution common first-line resuscitation fluid in patients with trauma, burns, diabetic ketoacidosis, or those
having surgery(1)
glucose 5% and glucose saline should not be used for fluid resuscitation(3)
rapidly dilute plasma sodium
distribute rapidly across all fluid compartments and only modestly increase intravascular volume
Comparative efficacy of different crystalloids:

high-chloride crystalloids (such as 0.9% saline) may increase risk of acute kidney injury and metabolic
acidosis compared to low-chloride crystalloids in patients having IV fluid resuscitation for acute illness or
undergoing surgery (level 2 [mid-level] evidence)
based on systematic review of trials with methodologic limitations
systematic review of 21 studies (15 randomized trials, 1 controlled clinical trial, and 5 observational studies) comparing
high-chloride vs. low-chloride crystalloids for IV fluid resuscitation in 6,253 patients with acute illness or having surgery
high-chloride crystalloid was 0.9% saline (154 mmol/L chloride)
low-chloride crystalloids included Ringer lactate (109 mmol/L chloride), Hartmann solution (111 mmol/L chloride),
and Plasma-Lyte (98 mmol/L chloride)
trials included in meta-analyses had ≥ 1 limitation
unclear or no methods of randomization sequence generation
unclear or no blinding of patients, caregivers, or outcome assessors
comparing high-chloride to low-chloride crystalloids
high-chloride crystalloids associated with increased risk of
acute kidney injury or renal failure (risk ratio 1.64, 95% CI 1.27-2.13) in analysis of 8 studies with 5,570
patients; significant results driven by 1 controlled clinical trial with 1,533 patients
hyperchloremia or metabolic acidosis (risk ratio 2.87, 95% CI 1.95-4.21) in analysis of 3 studies with 193
patients
no significant difference in mortality in analysis of 6 studies with 5,430 patients
Reference - Br J Surg 2015 Jan;102(1):24 full-text
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hypertonic and isotonic saline associated with similar mortality in patients with traumatic hypovolemic shock
(level 1 [likely reliable] evidence)
based on systematic review
systematic review of 6 randomized trials comparing hypertonic saline vs. isotonic saline in 1,254 patients with traumatic
hypovolemic shock
all hypertonic saline groups used 7.5% saline 250 mL
isotonic saline groups included 250 mL of normal (0.9%) saline in 3 trials and lactated Ringer in 3 trials
comparing hypertonic saline vs. isotonic saline
no significant differences in mortality in analysis of all trials
hypertonic saline associated with greater increase in
systolic blood pressure (weighted mean difference 6.47 mm Hg, 95% CI 1.31-11.63 mm Hg) in analysis of 5
trials with 1,184 patients
postinfusion serum sodium level (weighted mean difference 7.94 mmol/L, 95% CI 7.38-8.51 mmol/L) in analysis
of 4 trials with 1,068 patients
Reference - J Surg Res 2014 Oct;191(2):448
hypertonic and isotonic crystalloid solutions for volume replacement might have similar mortality in patients
with trauma or burns or having surgery (level 2 [mid-level] evidence)
based on Cochrane review with wide confidence intervals
systematic review of 14 randomized trials comparing hypertonic vs. isotonic or near isotonic crystalloid solutions for
volume replacement in 956 patients with trauma or burns or having surgery
11 trials compared hypertonic saline vs. Ringer lactate and 3 trials compared hypertonic saline vs. normal saline
6 trials included patients with trauma, 5 trials included patients having surgery, and 3 trials included patients with
burns
trial quality assessment only reported allocation concealment and blinding
no significant differences in mortality in analysis of
6 trials with 651 patients with trauma (risk ratio [RR] 0.84, 95% CI 0.69-1.04)
5 trials with 230 patients having surgery (RR 0.51, 95% CI 0.09-2.73)
3 trials with 89 patients with burns (RR 1.49, 95% CI 0.56-3.95)
all analyses for mortality were limited by wide confidence intervals that include possibility of benefit or harm
no significant differences in disability in 1 trial including 226 patients with trauma
Reference - Cochrane Database Syst Rev 2004;(3):CD002045 EBSCOhost Full Text (review updated 2008 Feb 20
with no new studies added with new search)
fluid resusciation with balanced crystalloids may minimally reduce major adverse kidney events compared to
saline in critically ill adults (level 2 [mid-level] evidence)
based on cluster randomized crossover trial without blinding
5 intensive care units were randomized to IV fluid resuscitation with balanced crystalloids (lactated Ringer's solution or
Plasma-Lyte A) vs. saline (0.9% sodium chloride) for first month and then alternated monthly for duration of trial
15,802 adults (median age 58 years, 57.6% male) with critical illness (sepsis in 14%, traumatic brain injury in 9%, and
mechanical ventilation in 35%) were enrolled
major adverse kidney event defined as composite of death from any cause, new renal-replacement therapy, or persistent
renal dysfunction (defined as elevated creatinine level ≥ 200% of baseline), all censored at hospital discharge or 30 days
(whichever occurred first)
comparing balanced crystalloids vs. saline
major adverse kidney event at 30 days in 14.3% vs. 15.4% (p = 0.04, NNT 99)
in-hospital mortality 10.3% vs. 11.1% (p = 0.06)
new renal-replacement therapy in 2.5% vs. 2.9% (p = 0.08)
persistent renal dysfunction in 6.4% vs. 6.6% (not significant)
consistent results for major adverse kidney events in subgroup of 2,336 patients with sepsis
Reference - SMART trial (N Engl J Med 2018 Mar 1;378(9):829), editorial can be found in N Engl J Med 2018 Mar
1;378(9):862
saline and balanced crystalloids may have similar rates of major adverse kidney events in patients admitted
to intensive care unit (level 2 [mid-level] evidence)
based on cluster randomized crossover trial without blinding
1 medical intensive care unit (ICU) was randomized to isotonic saline vs. balanced crystalloid (physician's choice of
lactated Ringer or Plasma-Lyte A) for first month of trial and then was alternated monthly for duration of trial
all decisions regarding management of fluid resuscitation (frequency, rate, total volume, and additive content of
crystalloids) were made by treating physician
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no restrictions were placed on other fluids or therapies and fluid administered outside ICU was not controlled by trial
974 adults (median age 58 years) admitted to ICU were included (454 received saline and 520 balanced crystalloids)
major adverse kidney events defined as in-hospital mortality, new renal replacement therapy, or persistent renal
dysfunction (inpatient serum creatinine ≥ 200% of baseline)
percent of total crystalloids given as saline was 91.2% during saline months vs. 21.2% during balanced crystalloid
months (p < 0.001)
comparing saline vs. balanced crystalloids
major adverse kidney events at 30 days in 24.7% vs. 24.6% (not significant)
ICU mortality 9.7% vs. 8.7% (not significant)
acute kidney injury in 28.4% vs. 26% (not significant)
new renal replacement therapy in 3.1% vs. 4.6% (not significant)
final creatinine > 200% baseline in 13% vs. 14.6% (not significant)
no significant difference in median volume of crystalloid given, use of other IV fluids or blood products, or 30-day
mortality
Reference - Am J Respir Crit Care Med 2017 May 15;195(10):1362
hypertonic solution with or without dextran may not reduce mortality compared to isotonic or Ringer's lactate
solutions in trauma patients with hemorrhagic shock (level 2 [mid-level] evidence)
based on systematic review with wide confidence intervals
systematic review of 12 randomized trials evaluating hypertonic fluids in 2,932 patients with hemorrhagic shock
6 trials compared hypertonic saline 7.5% vs. isotonic saline or Ringer's lactate solution
11 trials compared hypertonic solution 7.5% plus dextran vs. isotonic saline or Ringer's lactate solution
no significant difference in mortality (all not significant but CI includes possibility of benefit or harm)
comparing hypertonic saline to isotonic saline (risk ratio 0.96, 95% CI 0.82-1.12) in analysis of 6 trials
comparing hypertonic saline plus dextran to isotonic saline (risk ratio 0.92, 95% CI 0.8-1.06) in analysis of 11 trials
Reference - Anesth Analg 2017 Nov;125(5):1549
3% hypertonic saline solution causes fewer complications than 7.5% hypertonic saline solution or lactated
Ringer solution while maintaining similar efficacy for hemodynamic restoration in severe trauma patients
receiving fluid support (level 1 [likely reliable] evidence)
based on randomized trial
246 patients ≥ 15 years old (mean age 45 years, 77% male) with severe trauma and hypovolemic shock (prehospital
systolic blood pressure ≤ 70 mm Hg or 70-90 mm Hg and heart rate ≥ 108 beats/minute) were randomized to 250 mL
bolus of 3% hypertonic saline solution (HSS) vs. 7.5% HSS vs. lactated Ringer solution and were followed for up to 28
days
supplemental isotonic fluids were administered after randomized bolus as necessary to restore hemodynamic
stability
mean arterial pressure, blood pressure, and heart rate were recorded before fluid infusion and at 10, 30, 45, and 60
minutes after infusion; electrolyte levels, urine volume, and resuscitation fluid volume were monitored during first 24
hours
preinfusion mean arterial pressure 49 mm Hg with 3% HSS vs. 51 mm Hg with 7.5% HSS vs. 52 mm Hg with lactated
Ringer
Hemodynamic Variables:
3% HSS 7.5% HSS Lactated Ringer

mean arterial pressure at 10 67 mm Hg* 64 mm Hg* 55 mm Hg
minutes after infusion†
heart rate at 10 minutes after 118 beats/minute 127* beats/minute 114 beats/minute
infusion†
infusion volume in 1 hour 1.1 L* 1 L* 2.1 L
Abbreviations: HSS, hypertonic saline solution.
*p < 0.05 vs. Lactated Ringer
†data estimated from figure
Postinfusion Complications:
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Complications 3% HSS 7.5% HSS Lactated Ringer

Total 11% 39% 36%
Tachycardia 6% 28% 5%
Coagulopathy 0% 3% 11%*#
Acute renal failure 0% 0% 6%*#
Pulmonary edema 0% 0% 5%*#
Transient hypotension 0% 5%* 0%
Abbreviations: HSS, hypertonic saline solution.
*p < 0.05 among groups (pairwise comparisons not reported)
#p < 0.001 vs. HSS groups

overall 24-hour mortality was 12.2%, with no significant difference among groups
Reference - Shock 2015 Mar;43(3):244
resuscitation with addition of balanced fluids to nonbalanced fluids associated with decreased risk of in-
hospital mortality in adults (level 2 [mid-level] evidence)
based on retrospective cohort study
53,448 patients with sepsis not having surgery and treated with vasopressors and crystalloids over first 2 days in
intensive care unit (ICU) were evaluated
crystalloids included mainly lactated Ringer solution (balanced) and isotonic saline (nonbalanced)
in propensity-matched analysis, 3,365 patients (median age 64 years) receiving resuscitation with nonbalanced plus
balanced fluids (balanced) were compared to 3,365 patients receiving resuscitation with nonbalanced fluids only
(nonbalanced)
patients in balanced fluids group received different proportions of balanced and nonbalanced fluids, < 1% received
balanced fluids only
in-hospital mortality 19.6% with balanced fluids vs. 22.8% with nonbalanced fluids (p = 0.001, NNT 32)
no significant differences in
acute renal failure with or without dialysis
length of in-hospital or ICU stay
Reference - Crit Care Med 2014 Jul;42(7):1585
low-dose hypotonic resuscitation fluid may increase oliguria and tachycardia without decreasing shock or
mortality compared to lactated Ringer in malnourished children in Kenya (level 2 [mid-level] evidence)
based on randomized trial with early termination
61 children > 6 months old (mean age 16 months, 59% male) with severe malnutrition and hypovolemic shock or
presumptive septic shock were randomized to 1 of 2 fluid resuscitation regimens
low-dose hypotonic fluid resuscitation (half-strength Darrows/5% dextrose) to maximum of 2 boluses of 15 mL/kg
over 2 hours
lactated Ringer isotonic fluid 10 mL/kg every half hour to maximum 40 mL/kg
trial was terminated early without prespecified stopping rule before targeted enrollment of 90 children
comparing hypotonic fluid vs. lactated Ringer fluid
oliguria at 8 hours in 41% vs. 12% (p = 0.02, NNH 3)
tachycardia at 24 hours in 44% vs. 16% (p = 0.04, NNT 4)
persistent shock at 8 hours in 68% vs. 56% (not significant)
persistent shock at 24 hours in 78% vs. 56% (not significant)
in-hospital mortality 58% vs. 45% (not significant)
Reference - BMC Pediatr 2010 Oct 6;10:71 full-text
Colloids
Types of colloids:
Type and Composition of Colloid Resuscitation Fluids(1, 2, 3):
Solution* Osmolarity Sodium Chloride Oncotic Half Life
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Pressure
Reference Human plasma 291 mOsm/L 135-145 mmol/L 94-111 mmol/L -- --
Albumins 5% Albumin 309 mOsm/L 145 mmol/L 145 mmol/L 20 mm Hg 20 days
25% Albumin 312 mOsm/L 145 mmol/L 145 mmol/L 100 mm Hg 20 days
HES 6% HES 130/0.4 286-308 137-154 mmol/L 110-154 mmol/L 36 mm Hg 12 hours

mOsm/L
6% HES 450/0.7 308 mOsm/L 143-154 mmol/L 124-154 mmol/L 27.5 mm Hg 3 days
10% HES 308 mOsm/L 154 mmol/L 154 mmol/L 57.5 mm Hg 12 hours
260/0.45
Gelatin 4% succinylated 274 mOsm/L 154 mmol/L 120 mmol/L NA NA

modified fluid
gelatin
3.5% urea- 301 mOsm/L 154 mmol/L 154 mmol/L NA NA

linked gelatin
Abbreviations: HES, hydroxyethyl starches; NA, not applicable.
*different commercially available brands may vary in composition

colloid solutions contain large molecular weight molecules largely unable to cross capillary membranes suspended in carrier
solution(1, 2, 3)
more expensive and less widely available than crystalloids(2)
colloids remain within intravascular space and maintain colloid oncotic pressure(1, 3)
theoretically more effective at expanding intravascular volume than crystalloids
less volume may be needed to maintain intravascular volume
Albumin:
human albumin (4%-5% in saline) considered reference colloid solution(1)
fractionated blood product heat treated to prevent pathogen transmission
expensive to produce and distribute
limited availability in low- and middle-income countries
albumin is not recommended for routine care, but National Clinical Guideline Centre (United Kingdom) 2013 guidelines on IV
fluidtherapy in adults in hospital and Surviving Sepsis Campaign guidelines suggest albumin 4%-5% may be considered in
patients with severe sepsis or septic shock requiring substantial amounts of crystalloids (SCCM Weak recommendation, Low-
quality evidence )
human albumin does not reduce mortality in critically ill patients with hypovolemia (level 1 [likely reliable]
evidence), may not reduce mortality in patients with hypoalbuminemia (level 2 [mid-level] evidence), and
may increase mortality in burn patients (level 2 [mid-level] evidence)
based on Cochrane review
systematic review of 38 randomized trials comparing human albumin or plasma protein fraction vs. control in 10,842
critically ill patients with hypovolemia, hypoalbuminemia, or burns
control groups included crystalloid solutions or no albumin or plasma protein fraction administration
no included trials evaluated plasma protein fraction
compared to control, albumin associated with increased mortality in analysis of 4 trials with 205 patients with burns
odds ratio 2.93 (95% CI 1.28-6.72)
NNH 3-44 with 9% mortality in placebo or no treatment group
no significant differences in mortality comparing albumin to control
in analysis of 22 trials with 9,880 patients with hypovolemia, SAFE trial (described below) provided 75.2% of weight
in analysis
in analysis of 12 trials with 757 patients with hypoalbuminemia, wide confidence intervals cannot exclude clinically
relevant differences between groups
Reference - Cochrane Database Syst Rev 2011 Nov 9;(11):CD001208 EBSCOhost Full Text
albumin and saline have similar outcomes for fluid resuscitation in intensive care units (level 1 [likely
DynaMed 10/2/19 19'46
reliable] evidence)
6,997 adults (mean age 58 years, 60% male) admitted to intensive care unit (ICU) requiring fluid administration to
maintain or increase intravascular volume were randomized to albumin 4% (Albumex) vs. normal saline
patients were excluded for ICU admission following cardiac surgery, liver transplantation, or burn treatment
all patients received maintenance fluids, replacement fluids, enteral/parenteral nutrition, and blood products
according to treating clinician
17% were admitted for trauma, 17.4% for severe sepsis
99% were included in analysis
compared to saline group, albumin group had significantly
lower mean volume of trial fluid administration on and net positive fluid balance on days 1-3
higher mean volume of packed red cells administered on days 1-2
lower mean central venous pressure and serum albumin on days 1-4
comparing albumin vs. saline
28-day mortality 20.9% vs. 21.1% (not significant)
mean length of ICU stay 6.5 days vs. 6.2 days (not significant)
mean length of hospital stay 15.3 days vs. 15.6 days (not significant)
new organ failure in 47.3% vs. 46.7% (not significant)
comparing albumin vs. saline in subgroup analyses, 28-day mortality
13.6% vs. 10% in patients with trauma (p = 0.06)
30.7% vs. 35.3% in patients with severe sepsis (p = 0.09)
no significant differences in 28-day mortality subgroup analyses of patients with acute respiratory distress syndrome
Reference - SAFE trial (N Engl J Med 2004 May 27;350(22):2247 full-text), editorial can be found in N Engl J Med 2004
May 27;350(22):2294, commentary can be found in CMAJ 2004 Aug 3;171(3):232, ACP J Club 2004 Sep-Oct;141(2):29,
N Engl J Med 2004 Oct 28;351(18):1905, FDA 2005 May 16
baseline serum albumin level might not influence effect of albumin administration on mortality (level 2
[mid-level] evidence)
based on subgroup analysis of SAFE trial
6,045 patients from SAFE trial were assessed by baseline serum albumin concentrations
2,451 patients (mean age 61 years, 59% male) had baseline serum albumin ≤ 25 g/L
3,589 patients (mean age 56 years, 61% male) had baseline serum albumin > 25 g/L
28-day mortality comparing albumin vs. saline
23.7% vs. 26.2% in patients with serum albumin ≤ 25 g/L (not significant)
19.8% vs. 18.5% in patients with serum albumin > 25 g/L (not significant)
Reference - BMJ 2006 Nov 18;333(7577):1044 full-text, correction can be found in BMJ 2006 Nov 25;333(7578),
editorial can be found in BMJ 2006 Nov 18;333(7577):1029 full-text
albumin or plasma protein fraction may not reduce mortality compared to crystalloids in critically ill patients
requiring fluid replacement (level 2 [mid-level] evidence)
based on Cochrane review with incomplete assessment of trial quality
systematic review of 78 randomized trials comparing colloids to crystalloids in critically ill patients requiring fluid
replacement
only 13 trials had adequate allocation concealment, only 7 of these had > 50 patients; these trials may have had
adequate blinding and low loss to follow-up but trial-specific assessment of blinding and loss to follow-up not reported
no significant difference in mortality comparing albumin or plasma protein fraction to crystalloids in analysis of 24 trials
with 9,920 patients
Reference - Cochrane Database Syst Rev 2013 Feb 28;(2):CD000567 EBSCOhost Full Text
albumin might reduce mortality compared to crystalloids in adults with sepsis, with and without shock (level
2 [mid-level] evidence)
based on 3 systematic reviews with borderline statistical significance and methodologic limitations
systematic review of 16 randomized trials comparing fluid volume expansion and resuscitation with albumin solution vs.
control fluid (crystalloid [0.9% saline or Ringer lactate] or colloid [hydroxyethyl starch or gelatin]) in 4,190 adults with
sepsis in critical or intensive care
studies included patients with sepsis, severe sepsis, and septic shock
follow-up ranged from intensive care discharge to 90 days
comparing albumin to crystalloid fluid, albumin associated with nonsignificant reduction in mortality (relative risk
0.93, 95% CI 0.86-1.01) in analysis of 7 trials with 3,878 adults
no significant difference in mortality comparing albumin to colloid fluid in analysis of 11 trials with 299 adults
http://web.a.ebscohost.com.wdg.biblio.udg.mx:2048/dynamed…pdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d#AN=906227&db=dme Página 10 de 21
DynaMed 10/2/19 19'46
Reference - BMJ 2014 Jul 22;349:g4561, correction can be found in BMJ 2014 Jul 28;349:g4850
systematic review of 17 randomized trials comparing albumin vs. control (crystalloid, starch, or Gelofusine) as
resuscitation fluid in 1,977 patients with sepsis
all trials had ≥ 1 methodologic limitation, including unclear allocation concealment, incomplete blinding, or lack of
prespecified sepsis subgroups
comparing albumin to control therapy, albumin associated with nonsignificant reduction in mortality (odds ratio [OR]
0.82, 95% CI 0.67-1) in analysis of all trials
no significant difference in analysis of 15 studies with 1,729 adults
larger benefit in analysis of 3 trials with 248 children (OR 0.29, 95% CI 0.12-0.72)
reduced mortality with
dilute albumin solutions (4%, 4.5%, or 5%) vs. control (OR 0.76, 95% CI 0.61-0.95) in analysis of 9 trials with
1,594 patients
albumin therapy vs. crystalloid fluidtherapy (OR 0.78, 95% CI 0.62-0.99) in analysis of 7 trials with 1,441
patients
no significant difference in mortality comparing
albumin solution vs. starch in analysis of 12 trials with 463 patients
albumin solution vs. Gelofusine in analysis of 2 trials with 100 patients
concentrated albumin solutions (≥ 20%) vs. control in analysis of 8 trials with 383 patients
Reference - Crit Care Med 2011 Feb;39(2):386, editorial can be found in Crit Care Med 2011 Feb;39(2):418
systematic review of 5 studies comparing albumin vs. crystalloids for fluid resuscitation in 5,838 patients with severe
sepsis or septic shock
clinical heterogeneity included variation in albumin concentrations (4%-5% in 3 trials, 20% in 1 trial, both in 1 trial),
crystalloid solutions (normal saline in 2 trials, Ringer lactate in 1 trial, variety of crystalloids in 2 trials), and differing
mortality end points across studies
compared to crystalloids, albumin associated with
decreased 90-day mortality in patients with septic shock (odds ratio 0.81, 95% CI 0.47-0.97) in subgroup
analysis of 2,186 patients from 4 trials
nonsignificant decrease in 90-day mortality in patients with severe sepsis (OR 0.88, 95% CI 0.76-1.01) in
subgroup analysis of 3,650 patients from 5 trials
no significant differences in 28-day mortality in patients with severe sepsis in subgroup analysis of 3,664 patients
from 5 trials
Reference - Crit Care 2014 Dec 15;18(6):702 full-text
albumin plus crystalloids may not reduce 28-day mortality compared to crystalloids alone in patients with
severe sepsis or septic shock, but might reduce 90-day mortality in patients with shock (level 2 [mid-
level] evidence)
based on randomized trial without blinding and post hoc subgroup analysis
1,818 adults (median age 69 years) in intensive care unit (ICU) with severe sepsis or septic shock (62.7%) were
randomized to 20% albumin plus crystalloid solution vs. crystalloid solution alone until ICU discharge or 28 days
albumin group received 300 mL of 20% albumin solution at baseline, with daily administration of 20% albumin
to maintain serum concentration ≥ 30 g/L
all patients could receive crystalloids at any time as clinically indicated
patients were randomized upon meeting clinical criteria for severe sepsis within previous 24 hours at any time during
ICU stay (31.8% of patients were enrolled at < 6 hours), and had goal-directed therapy in early phase of volume
resuscitation
98.7% included in analysis
comparing albumin plus crystalloids vs. crystalloids alone
28-day all-cause mortality 31.8% vs. 32% (not significant)
90-day all-cause mortality in subgroup analyses
43.6% vs. 49.9% (p = 0.03, NNT 16) in patients with septic shock
37% vs. 32.7% (not significant) in patients without septic shock
consistent results for 28-day mortality in subgroup analysis stratified by time to randomization (< 6 hours or 6-24
hours)
during first 7 days, albumin plus crystalloids associated with higher mean arterial pressure (p = 0.03) and lower net
fluid balance (p < 0.001) compared to crystalloids alone
no significant differences in organ dysfunction or in length of ICU or total hospital stay
Reference - ALBIOS trial (N Engl J Med 2014 Apr 10;370(15):1412 full-text), commentary can be found in N Engl J
Med 2014 Jul 3;371(1):84
http://web.a.ebscohost.com.wdg.biblio.udg.mx:2048/dynamed…NpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d#AN=906227&db=dme Página 11 de 21
DynaMed 10/2/19 19'46
Hydroxyethyl starch:
semisynthestic colloids have been developed due to expense and limited availability of albumin(1)
hydroxyethyl starch solutions are most commonly used
other semisynthetic colloids include gelatin and dextran solutions
hydroxyethyl starch solutions are made with hydroxyethyl substitution of amylopectin from sorghum, maize, or potatoes(1)
substitution on glucose molecules protects against hydrolysis by nonspecific amylases in blood and prolongs intravascular
expansion
substitution may also allow hydroxyethyl starch molecules to build up in tissues including skin, liver, and kidney
hydroxyethyl starches vary in molecular weight, percentage of molecular substitution, and concentration and are available in
different crystalloid carrier solutons(1, 2)
associated with coagulation alterations, especially with high-molecular-weight starches(1)
maximum daily recommended dose 33-50 mL/kg due to potential accumulation in tissues(1)
National Clinical Guideline Centre (United Kindom) 2013 guidelines on IV fluidtherapy in adults in hospital and Surviving
Sepsis Campaign guidelines recommend against starches for fluid resuscitation (SCCM Strong recommendation, High-quality
evidence ) due to increased risk of kidney dysfunction
suspension of marketing authorization of hydroxyethyl starch solutions for infusion has been recommended in the European
Union due to continued use in patient populations at risk of kidney injury and death (such as critically ill patients and patients
with sepsis) despite guideline recommendations (European Medicines Agency (EMA) 2018 Jan 26)
hydroxyethyl starch does not decrease mortality and increases risk of renal replacement therapy compared to
other fluid resuscitation agents in patients requiring fluid resuscitation (level 1 [likely reliable] evidence)
based on 3 systematic reviews and 1 additional randomized trial
systematic review of 42 randomized or quasi-randomized trials comparing hydroxyethyl starch vs. other fluid
resuscitation therapies (control) in 11,399 patients with effective intravascular volume depletion
comparison fluids included gelatin, normal saline, Ringer lactate or acetate, albumin, Hartmann solution, and
balanced plasma solution
indications for treatment included sepsis, burns, cardiac surgery, vascular surgery, noncardiac surgery,
gastrointestinal bleeding, hypovolemic shock, and trauma
hydroxyethyl starch associated with increased risk of
renal failure in analysis of 15 trials with 1,361 patients
risk ratio 1.59 (95% CI 1.26-2)
NNH 8-32 with renal failure in 12% of control group
renal replacement therapy in analysis of 19 trials with 9,857 patients
risk ratio 1.31 (95% CI 1.16-1.49)
NNH 25-78 with renal replacement therapy in 8% of control group
Reference - Cochrane Database Syst Rev 2013 Jul 23;(7):CD007594 EBSCOhost Full Text
systematic review of 38 randomized trials comparing hydroxyethyl starch vs. other resuscitation fluids in critically ill
patients receiving acute volume resuscitation
other resuscitation fluids included crystalloids, albumin, or gelatin
hydroxyethyl starch associated with
increased use of renal replacement therapy (risk ratio 1.32, 95% CI 1.15-1.5) in analysis of 10 trials with 9,258
patients
increased risk of renal failure (risk ratio 1.27, 95% CI 1.09-1.47) in analysis of 5 trials with 8,725 patients
nonsignificant increase in mortality (relative risk 1.06, 95% CI 1-1.13) in analysis of 35 studies with 10,880
patients
increased mortality (risk ratio 1.09, 95% CI 1.02-1.17) in analysis limited to 28 trials with 10,290 patients (7
trials excluded by same author whose subsequent research was retracted because of scientific misconduct)
Reference - JAMA 2013 Feb 20;309(7):678, correction can be found in JAMA 2013 Mar 27;309(12):1229, editorial
can be found in JAMA 2013 Feb 20;309(7):723
similar results in systematic review of 35 randomized trials comparing 6% hydroxyethyl starch vs. other resuscitation
fluids in 10,391 acutely ill adult patients (Intensive Care Med 2013 Apr;39(4):558), editorial can be found in Intensive
Care Med 2013 Apr;39(4):782
7,000 patients (mean age 63 years, 60% male) admitted to intensive care unit were randomized to fluid resuscitation
with 6% hydroxyethyl starch vs. 0.9% saline and were followed for 90 days
fluid resuscitation defined as administration of additional IV fluid bolus beyond general maintenance or replacement
fluid requirements (fluid administered to correct hypovolemia at any time during intensive care unit admission)
hydroxyethyl starch had molecular weight 130 kilodaltons (kDa) and molar substitution ratio 0.4 in 0.9% saline
patients were excluded for receiving > 1,000 mL hydroxyethyl starch before screening, impending or current
DynaMed 10/2/19 19'46
dialysis-dependent renal failure, or evidence of intracranial hemorrhage on computed tomography

maximum trial fluid administration was 50 mL/kg/day followed by 0.9% saline for remainder of 24-hour period
for all patients
95% completed 90-day follow-up and were included in analysis
fluid administration during first 4 day comparing hydroxyethyl starch vs. saline
mean daily volume trial fluid administration 526 mL vs. 616 mL (p < 0.001)
mean daily volume nonstudy fluid administration 851 mL vs. 1,115 mL (p < 0.001)
mean volume blood product administration 78 mL vs. 60 mL (p < 0.001)
comparing hydroxyethyl starch vs. saline at 90 days
all-cause mortality 18% vs. 17% (not significant)
renal replacement therapy in 7% vs. 5.8% (p = 0.04, NNH 83)
renal injury in 34.6% vs. 38% (p = 0.005, NNT 30)
renal failure in 10.4% vs. 9.2% (p = 0.1)
adverse events (pruritus and skin rash most common) in 4.6% vs. 3.3% (p = 0.006, NNH 77)
Reference - CHEST trial (N Engl J Med 2012 Nov 15;367(20):1901 full-text), correction can be found in N Engl J Med
2016 Mar 31;374(13):1298, commentary can be found in N Engl J Med 2013 Feb 21;368(8):774
patients with sepsis
fluid resuscitation with hydroxyethyl starch does not decrease mortality and increases risk of renal
replacement therapy compared to crystalloid or albumin in patients with sepsis (level 1 [likely reliable]
evidence)
based on systematic review
systematic review of 9 randomized trials comparing fluidtherapy with hydroxyethyl starch (molecular weight 130
kilodaltons [kDa]/substitution ratio 0.38-0.45) to crystalloids or albumin in 3,456 patients with sepsis
7 trials included patients with severe sepsis (sepsis and organ failure) and only subgroup analysis of patients
with sepsis was included from 1 trial
comparator was crystalloids in 7 trials and albumin in 2 trials
no significant difference in all-cause mortality in analysis of 8 trials with 3,414 patients
compared to crystalloids or albumin, hydroxyethyl starch associated with
increased risk of renal replacement therapy (risk ratio [RR] 1.36, 95% CI 1.08-1.72) in analysis of 5 trials with
1,311 patients
increased risk of red blood cell transfusion (RR 1.29, 95% CI 1.13-1.48) in analysis of 3 trials with 973 patients
increased risk of serious adverse events (RR 1.3, 95% CI 1.02-1.67) in analysis of 4 trials with 1,069 patients
nonsignificant increase in mortality (RR 1.11, 95% CI 1-1.23) in sensitivity analysis of 4 trials with low risk of
bias
Reference - BMJ 2013 Feb 15;346:f839 full-text
hydroxyethyl starch increases risk of mortality and renal replacement therapy compared to Ringer
acetate in patients with severe sepsis (level 1 [likely reliable] evidence)
804 patients ≥ 18 years old (median age 67 years, 61% male) with severe sepsis requiring fluid resuscitation were
randomized to 6% hydroxyethyl starch 130/0.42 vs. Ringer acetate with maximum dose of 33 mL/kg/day ideal body
weight
patients requiring fluid doses higher than daily maximum received Ringer acetate regardless of randomized group
99% were included in analysis
total volume blood products received was 1,340 mL with hydroxyethyl starch vs. 1,055 mL Ringer acetate (p =
0.003)
no significant differences in median volume of trial fluid, open-label trial fluid, or other fluids received
comparing hydroxyethyl starch vs. Ringer acetate at 90 days
mortality 51% vs. 43% (p = 0.03, NNH 12)
renal replacement therapy in 22% vs. 16% (p = 0.04, NNH 16)
dependence on dialysis in 0.25% vs. 0.25% (not significant)
severe bleeding in 10% vs. 6% (p = 0.09)
Reference - N Engl J Med 2012 Jul 12;367(2):124 full-text, correction can be found in N Engl J Med 2012 Aug
2;367(5):481
Comparisons of colloids:
individual colloids may have similar mortality in critically ill or surgical patients having volume replacement
(level 2 [mid-level] evidence)
DynaMed 10/2/19 19'46

systematic review of 86 randomized trials comparing colloid solutions in 5,484 critically ill or surgical patients requiring
volume replacement
trials quality assessment was based only on presence or absence of allocation concealment
large proportion of trials had small sample size and reported no deaths
albumin or plasma protein fraction to hydroxyethyl starch in analysis of 31 trials with 1,719 patients
albumin or plasma protein fraction to gelatin in analysis of 9 trials with 824 patients
albumin or plasma protein fraction to dextran 70 in analysis of 4 trials with 360 patients
modified gelatin to hydroxyethyl starch in analysis of 22 trials with 1,612 patients
Reference - Cochrane Database Syst Rev 2012 Jul 11;(7):CD001319 EBSCOhost Full Text
individual colloids may differ in safety (level 2 [mid-level] evidence)
based on systematic review without assessment of trial quality
systematic review of 113 studies with 1.54 million patients receiving 109 million colloid infusions
compared to albumin as reference colloid, anaphylactoid reactions were
12.4 times more common with gelatin
4.5 times more common with hydroxyethyl starch
2.3 times more common with dextran
hydroxyethyl starch more likely than albumin to be associated with pruritus, coagulopathy, and clinical bleeding
Reference - Arch Surg 2004 May;139(5):552
Comparing Crystalloids vs. Colloids
mortality may be increased with hydroxyethyl starch but not with other colloids compared to crystalloids in
critically ill patients requiring fluid replacement (level 2 [mid-level] evidence)
systematic review of 78 randomized trials comparing colloids to crystalloids in critically ill patients requiring fluid
replacement
only 13 trials had adequate allocation concealment and only 7 of these had > 50 patients; these trials may have had
adequate blinding and low loss to follow-up, but trial-specific assessment of blinding and loss to follow-up were not
reported
hydroxyethyl starch associated with increased mortality compared to crystalloids in analysis of 25 trials with 9,147
patients
risk ratio 1.1 (95% CI 1.02-1.19)
NNH 26-250 with 20% mortality in crystalloids group
albumin or plasma protein fraction to crystalloids in analysis of 24 trials with 9,920 patients
modified gelatin to crystalloids in analysis of 11 trials with 506 patients
dextran to crystalloids in analysis of 9 trials with 834 patients
hydroxyethyl starch in hypertonic crystalloid solution to isotonic crystalloid solution in 1 trial with 90 patients
dextran in hypertonic crystalloid solution to isotonic crystalloid solution in analysis of 9 trials with 1,879 patients
Reference - Cochrane Database Syst Rev 2013 Feb 28;(2):CD000567 EBSCOhost Full Text
balanced crystalloids may slightly reduce major adverse kidney events compared to saline in noncritically ill
adults (level 2 [mid-level] evidence)
based on quasi-randomized trial without blinding
13,347 noncritically ill adults (median age 53 years) admitted to emergency department and subsequently hospitalized
outside intensive care unit assigned by calendar month to balanced crystalloid IV (Ringer lactate or Plasma-Lye A) vs.
0.9% saline IV
11.7% had off-protocol treatment with alternative crystalloids
patients were treated with median 1,079 mL of crystalloid volume
in intention-to-treat analysis
major adverse kidney events in 4.7% of balanced crystalloid group vs. 5.6% of saline group (p = 0.01, NNT 111)
no significant differences in median hospital-free days after discharge, rate of acute kidney injury ≥ stage 2, or in-
hospital mortality
similar results found in sensitivity and per-protocol analyses
Reference - SALT-ED trial (N Engl J Med 2018 Mar 1;378(9):819)
colloids may increase risk of acute kidney injury and renal replacement therapy, but may not increase
mortality compared to crystalloids in patients requiring volume replacement (level 2 [mid-level] evidence)
DynaMed 10/2/19 19'46
based on systematic review with clinical heterogeneity and without reporting of individual trial quality measures
systematic review of 59 randomized trials comparing colloids vs. crystalloids in 16,889 patients requiring volume
replacement
reasons for volume replacement included surgery (32 trials), critical care or sepsis (13 trials), traumatic injury (12
trials), heart failure (1 trial), or pancreatitis (1 trial)
colloids included in meta-analyses were tetrastarch (25 trials), pentastarch (11 trials), hexastarch (2 trials),
hetastarch (2 trials), hypertonic saline (7.5%)-dextran (13 trials),dextran-70 (1 trial), and gelatin (15 trials)
tetrastarch and pentastarch doses varied considerably among trials
most commonly used crystalloids were normal saline and lactated Ringer
compared to crystalloids, colloids associated with
increased risk of acute kidney injury in analysis of 14 trials with 9,755 patients
odds ratio (OR) (1.21, 95% CI 1.07-1.37)
NNH 26-136 with acute kidney injury in 12% of crystalloids group
increased risk of renal replacement therapy in analysis of 9 trials with 11,648 patients
OR 1.35 (95% CI 1.17-1.57)
NNH 32-105 with renal replacement therapy in 6% of crystalloids group
nonsignificant increase in risk of myocardial infarction (OR 2.32, 95% CI 0.96-5.58) in analysis of 5 trials with 895
patients
longer intensive care unit stay (weighted mean difference 0.4 days, 95% CI 0.39-0.41 days) in analysis of 14 trials
with 10,915 patients, results limited by significant heterogeneity
longer hospital stay (weighted mean difference 0.2 days, 95% CI 0.18-0.21 days) in analysis of 14 trials with 10,802
patients
no significant differences in
mortality in analysis of 32 trials with 16,647 patients
risk of sepsis in analysis of 6 trials with 2,074 patients
risk of stroke in analysis of 7 trials with 1,296 patients
in analyses by type of colloid
pentastarch associated with significantly increased mortality (4 trials), risk of acute kidney injury (1 trial), and risk of
renal replacement therapy (3 trials)
tetrastarch associated with significantly increased risk of renal replacement therapy (4 trials), but no significant
differences in mortality (13 trials) or risk of acute kidney injury (9 trials)
no significant differences in mortality or risk of acute kidney injury with
hypertonic saline-dextran (11 trials for mortality, 3 trials for acute kidney injury)
gelatin (6 trials for mortality, 1 trial for acute kidney injury)
Reference - Br J Surg 2016 Jan;103(1):14
fluid resuscitation with colloids may reduce mortality at 90 days, but not at 28 days, compared to
crystalloids in patients with hypovolemic shock (level 2 [mid-level] evidence)
based on randomized trial with difference in adherence to protocol between groups
2,857 patients with hypovolemic shock (54% with sepsis) in intensive care units (ICUs) at 57 centers were
randomized to 1 of 2 fluid resuscitation interventions
colloids including hypo-oncotic solutions (gelatins or albumin 4% or 5%) or hyperoncotic solutions (dextrans,
hydroxyethyl starches, or albumin 20% or 25%)
crystalloids including isotonic or hypertonic saline, or any buffered solution
patients were managed with fluids in randomized category until ICU discharge except for maintenance fluids
(isotonic crystalloids for all patients) or physician-directed administration of albumin for hypoalbuminemia (serum
albumin < 20 g/dL)
fluid administration prior to ICU admission (within 12 hours) in colloids vs. crystalloids groups
crystalloids in 37.2% vs. 27.9% (no p value reported)
colloids in 41.4% vs. 47.5% (no p value reported)
patients previously receiving resuscitation fluids in ICU were excluded
protocol violations occurred in 25.3% in colloids group vs. 6.5% in crystalloids group (no p value reported)
median cumulative fluid administration at day 7 was 2,000 mL with colloids vs. 3,000 mL with crystalloids (p <
0.001)
comparing colloids vs. crystalloids
28-day mortality 25.4% vs. 27% (not significant)
90-day mortality 30.7% vs. 34.2% (p = 0.03, NNT 29)
mean time alive without mechanical ventilation at 28 days 14.6 days vs. 13.5 days (p = 0.01)
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mean time alive without vasopressor therapy at 28 days 16.2 days vs. 15.2 days (p = 0.03)
renal replacement therapy in 11% vs. 12.5% (not significant)
mortality varied significantly across trial centers (p < 0.001)
no significant differences in length of intensive care unit stay or hospital stay at 28 days
Reference - CRISTAL trial (JAMA 2013 Nov 6;310(17):1809), editorial can be found in JAMA 2013 Nov
6;310(17):1803, commentary can be found in JAMA 2014 Mar 12;311(10):1069, Nat Rev Nephrol 2013
Dec;9(12):696, J Vasc Nurs 2014 Jun;32(2):70, and JAMA 2014 Mar 12;311(10):1067
hypertonic saline plus dextran associated with similar mortality and risk for acute respiratory distress
syndrome compared to lactated Ringer solution in trauma patients (level 2 [mid-level] evidence)
based on randomized trial with baseline differences between groups
209 patients aged 13-90 years (mean age 41 years) with blunt trauma and prehospital hypotension were
randomized to 7.5% hypertonic saline plus 6% dextran 70 (RescueFlow) 250 mL bolus vs. lactated Ringer solution
250 mL bolus
patients in hypertonic saline plus dextran group had higher hematocrit and lower serum sodium on admission (p <
0.001 for each) as well as higher total volume of prehospital IV fluid (p = 0.02)
trial was stopped for futility after second preplanned interim analysis using predefined stopping rule
comparing hypertonic saline plus dextran vs. lactated Ringer solution
acute respiratory distress syndrome (ARDS) in 22.7% vs. 16.2% (not significant)
28-day mortality 29.1% vs. 22.2% (not significant)
estimated 28-day ARDS-free survival 54% vs. 64% (not significant)
65% of deaths occurred within 48 hours of injury
no significant differences in mean number of ICU days, mean ventilator-free days, mean worst Multiple Organ
Dysfunction Score, and rate of any nosocomial infection
Reference - Arch Surg 2008 Feb;143(2):139
in patients with severe sepsis or septic shock
fluid resuscitation with high- or low-molecular-weight starches may increase risk of renal replacement
therapy compared to balanced colloids or saline in patients with severe sepsis or septic shock (level 2
[mid-level] evidence)
based on network meta-analysis with credibility intervals that includes differences that are not clinically important
systematic review and network meta-analysis of 10 randomized trials evaluating risk of renal replacement therapy
with fluid resuscitation in 6,664 adults with severe sepsis or septic shock
3 trials included mixed population of critically ill patients, but only subgroup of patients with sepsis were
included in analysis
1 trial did not provide results on individual fluids and could not be included in network meta-analysis
network meta-analysis reported results with credibility intervals (CrI) instead of confidence intervals due to
inclusion of indirect comparisons
in 6-node analysis comparing saline, balanced crystalloid, albumin, gelatin, high-molecular-weight hydroxyethyl
starch (H-HES), and low-molecular-weight hydroxyethyl starch (L-HES)
balanced crystalloids associated with reduced risk of renal replacement therapy compared to H-HES (OR 0.5,
95% CrI 0.34-0.74)
all other comparisons were nonsignificant, but credibility intervals suggest some interventions might be
beneficial
balanced crystalloids associated with nonsignificant reduction renal replacement therapy compared to L-
HES (OR 0.7, 95% CrI 0.49-1)
L-HES associated with nonsignificant increase in renal replacement therapy compared to saline (OR 1.21,
95% CrI 0.96-1.54)
H-HES associated with nonsignificant increase in renal replacement therapy compared to saline (OR 1.7,
95% CrI 0.97-3)
compared to crystalloids in direct analysis, increased risk of renal replacement therapy associated with
starch (odds ratio [OR] 1.39, 95% CI 1.17-1.65) in analysis of 8 trials with 3,893 adults
colloids (OR 1.26, 95% CI 1.1-1.45) in analysis of all 10 trials
Reference - Intensive Care Med 2015 Sep;41(9):1561
albumin and balanced saline may be associated with reduced mortality compared to saline or starches in
patients with severe sepsis or septic shock (level 2 [mid-level] evidence)
based on network meta-analysis with credibility intervals that includes differences that are not clinically important
systematic review and network meta-analysis of 14 trials comparing solutions for fluid resuscitation in 18,916 adults
with severe sepsis or septic shock
DynaMed 10/2/19 19'46
4 trials included critically ill patients with subgroup analysis for patients with sepsis
network meta-analysis reported results with CrI instead of confidence intervals due to inclusion of indirect
comparisons
in 6-node analysis comparing saline, balanced crystalloid, albumin, gelatin, H-HES, and L-HES
balanced crystalloids associated with reduced mortality compared to L-HES (odds ratio [OR] 0.75, 95% CrI 0.58-
0.97)
all other comparisons were nonsignificant, but credibility intervals suggest some interventions might be
beneficial
albumin associated with nonsignificant reduction in mortality compared to
saline (OR 0.82, 95% CrI 0.65-1.04)
L-HES (OR 0.79, 95% CrI 0.59-1.06)
balanced saline associated with nonsignificant reduction in mortality compared to
saline (OR 0.78, 95% CrI 0.58-1.05)
H-HES (OR 0.82, 95% CrI 0.6-1.13)
in 4-node analysis comparing crystalloids, albumin, starch, and gelatin
albumin associated with
reduced mortality compared to starch (OR 0.73, 95% CI 0.56-0.95)
nonsignificant reduction in mortality compared to crystalloids (OR 0.83, 95% CrI 0.65-1.04)
starch associated with nonsignificant increase in mortality compared to crystalloids (OR 1.13, 95% CrI 0.99-1.3)
Reference - Ann Intern Med 2014 Sep 2;161(5):347, commentary can be found in Ann Intern Med 2014 Nov
18;161(10):JC12, Ann Intern Med 2015 Feb 17;162(4):319, and Ann Emerg Med 2015 Nov;66(5):523
compared to resuscitation with isotonic saline only, combination treatment with saline plus balanced
crystalloids associated with reduced mortality, but combination of saline plus colloids associated with
increased mortality in adults with sepsis (level 2 [mid-level] evidence)
based on retrospective cohort study
60,734 adults admitted to intensive care units with sepsis were assessed for type of resuscitation fluid received
during days 1-2
all included patients received vasopressors by day 2, blood culture drawn by day 2, ≥ 3 consecutive days of
antibiotics IV, and ≥ 2 L of crystalloids by day 2
patients having major surgical procedures or transferred to or from other facilities were excluded
4 categories of IV fluid resuscitation administered on day 1 and 2 were assessed including isotonic saline only, saline
plus balanced crystalloids, saline plus colloids (hydroxyethyl starch or albumin), and saline plus balanced crystalloids
plus colloids
propensity scores for likelihood of receiving balanced crystalloids (vs. not) and colloids (vs. not) were calculated for
each patient
mortality in inverse probability weighting adjusted analysis controlling for confounding by treatment indication
21.35% with saline alone
18.83% with saline plus balanced crystalloids (p < 0.001 vs. saline alone)
25.36% with saline plus colloids (p < 0.001 vs. saline alone)
19.97% with saline plus balanced crystalloids plus colloids (not significant vs. saline alone)
consistent results in pairwise propensity-score matched analysis
Reference - Anesthesiology 2015 Dec;123(6):1385
Blood Substitutes
hemoglobin-based blood substitutes may increase mortality and risk of myocardial infarction in patients with
stroke, trauma, or undergoing an operative procedure (level 2 [mid-level] evidence)
based on systematic review without assessment of trial quality
systematic review of 16 randomized trials comparing hemoglobin-based blood substitutes vs. controls in 3,711 adults
with stroke, trauma, or having surgery
5 different hemoglobin-based blood substitutes were assessed including HemAssist, Hemopure, Hemolink,
PolyHeme, and Hemospan (range of partial pressure of oxygen required for 50% hemoglobin saturation [P50] 10-38
mm Hg and percentage of hemoglobin tetramer 1%-100%)
controls included blood, lactated Ringer solution, normal saline, packed red blood cells, hetastarch, or pentastarch
in analysis of all trials, hemoglobin-based blood substitutes associated with increased
mortality (relative risk [RR] 1.3, 95% CI 1.05-1.61)
risk of myocardial infarction (RR 2.71, 95% CI 1.67-4.4)
Reference - JAMA 2008 May 21;299(19):2304, correction can be found in JAMA 2008 Sep 17;300(11):1300, editorial can
DynaMed 10/2/19 19'46
be found in JAMA 2008 May 21;299(19):2324, commentary can be found in JAMA 2008 Sep 17;300(11):1295, ACP J Club
2008 Nov 18;149(5):4
Quality Improvement
Choosing Wisely:
Guidelines and Resources
Guidelines:
International guidelines:
Surviving Sepsis Campaign international guideline on management of severe sepsis and septic shock can be found in
Intensive Care Med 2017 Mar;43(3):304
Prevention and Management of Acute Renal Failure in the ICU Patient: an international consensus conference in intensive
care medicine can be found in Am J Respir Crit Care Med 2010 May 15;181(10):1128
International Society of Nephrology Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on acute
kidney injury can be found in KDIGO (2011) 2012 Mar PDF
United States guidelines:

Eastern Association for the Surgery of Trauma (EAST) practice management guidelines on prehospital fluid resuscitation for
the injured patient can be found in J Trauma 2009 Aug;67(2):389 PDF
United Kingdom guidelines:

National Institute for Health and Care Excellence (NICE) guideline on intravenous fluidtherapy in adults in hospital can be
found at NICE 2013 Dec:CG174 (updated May 2017) PDF
National Institute for Health and Care Excellence (NICE) guidance on prehospital initiation of fluid replacement therapy in
trauma can be found at NICE 2004 Jan:TA74 PDF
British Consensus Guidelines on Intravenous FluidTherapy for Adult Surgical Patients (GIFTASUP) can be found at GIFTASUP
2012 PDF
European guidelines:
European guideline on management of major bleeding and coagulopathy following trauma: fourth edition can be found in
Crit Care 2016 Apr 12;20:100
S3 Leitlinie Volumentherapie beim Erwachsenen finden Sie unter AWMF 2014 Jul PDF [Deutsch]
Australian and New Zealand guidelines:

New South Wales (NSW) Ministry of Health standards on paediatric intravenous fluids can be found at NSW 2015 Aug 31 PDF
Review articles:
review of fluid management in critically ill patients can be found in Kidney Dis (Basel) 2016 Jun;2(2):64
review of maintenance IV fluids in acutely ill patient can be found in N Engl J Med 2015 Oct;373(14):1350, commentary can
be found in N Engl J Med 2016 Jan 21;374(3):289
review of early fluid resuscitation in severe trauma can be found in BMJ 2012 Sep 11;345:e5752, commentary can be found
in BMJ 2012 Oct 30;345:e7205
review of shock resuscitation can be found in Lancet 2004 Jun 12;363(9425):1988 EBSCOhost Full Text
review of initial resuscitation of hemorrhagic shock can be found in World J Emerg Surg 2006 Apr 27;1:14 EBSCOhost
Full Text full-text
review of intravenous fluids for surgical patients can be found in Curr Opin Crit Care 2015 Aug;21(4):358
review of approach to fluidtherapy in patients with sepsis can be found in Br J Anaesth 2016 Mar;116(3):339
review of fluid and hemodynamic management in severe dengue can be found in Southeast Asian J Trop Med Public Health
2015;46 Suppl 1:123
review of human serum albumin and albumin solutions in patients with critical illness, sepsis, or cirrhosis can be found in
World J Hepatol 2016 Mar 8;8(7):345 full-text
Patient Information
DynaMed Editors have not identified patient education materials that meet our criteria for inclusion (freely accessible,
nonpromotional, topic-specific). We will continue to search for acceptable materials and welcome your suggestions.
ICD-9/ICD-10 Codes
DynaMed 10/2/19 19'46
ICD-9 codes:
276.0 hyperosmolality and/or hypernatremia
276.5 volume depletion disorder
276.50 volume depletion, unspecified
276.51 dehydration
276.52 hypovolemia
958.4 traumatic shock
785.59 other shock without mention of trauma
998.09 postoperative shock, other
ICD-10 codes:
E87.0 hyperosmolality and hypernatraemia
E86 volume depletion
ICD-10-CA modification in Canada
E86.0 dehydration
E86.8 other volume depletion (hypovolemia)
R57.1 hypovolemic shock
R57.9 shock, unspecific
T79.4 traumatic shock
References
General references used:

1. Myburgh JA, Mythen MG. Resuscitation fluids. N Engl J Med. 2013 Sep 26;369(13):1243-51 full-text
2. McGuire MD, Heung M. Fluid as a Drug: Balancing Resuscitation and Fluid Overload in the Intensive Care Setting. Adv
Chronic Kidney Dis. 2016 May;23(3):152-9
3. National Institute for Health and Clinical Excellence (NICE). Intravenous FluidTherapy: Intravenous FluidTherapy in Adults
in Hospital. NICE 2013 Dec:CG174 PDF
Recommendation grading systems used:

Society of Critical Care Medicine (SCCM) uses Grading of Recommendations, Assessment, Development, and Evaluation
(GRADE)
strength of recommendation
Strong - benefits clearly outweigh risks and burdens (or vice versa) for most, if not all, patients
Weak - benefits and risks closely balanced and/or uncertain
Best practice statement - recommendation not conducive to GRADE process
quality of evidence
High - randomized trials without factors that reduce quality of evidence, or well-done observational studies with very
large magnitude of effect
Moderate - downgraded randomized trials or upgraded observational studies
Low - well-done observational studies, or randomized trials with many limitations
Very low - case series or expert opinion
Reference - SCCM Surviving Sepsis Campaign 2016 international guideline on management of severe sepsis and septic
shock (Intensive Care Med 2017 Mar;43(3):304)
Task Force for Advanced Bleeding Care in Trauma (ABC-T) guideline grading system
Grade 1A
strong recommendation - benefits clearly outweigh risk and burdens, or vice versa
high-quality evidence based on randomized controlled trials without important limitations or overwhelming evidence
from observational studies
Grade 1B
moderate-quality evidence based on randomized, controlled trials with important limitations (inconsistent results,
methodological flaws, indirect or imprecise) or exceptionally strong evidence from observational studies
Grade 1C
low-quality or very low-quality evidence based on observational studies or case series
Grade 2A
weak recommendation - benefits closely balanced with risks and burdens OR uncertainty on the estimates of
benefits, risks, and burdens
DynaMed 10/2/19 19'46
high-quality evidence based on randomized controlled trials without important limitations or overwhelming evidence
from observational studies
Grade 2B
moderate-quality evidence based on randomized controlled trials with important limitations (inconsistent results,
methodological flaws, indirect or imprecise) or exceptionally strong evidence from observational studies
Grade 2C
low-quality or very low-quality evidence based on observational studies or case series
Reference - ABC-T European guideline on management of bleeding and coagulopathy following major trauma (Crit Care
2013 Apr 19;17(2):R76 full-text), commentary can be found in Crit Care 2013 Jul 31;17(4):442
Kidney Disease: Improving Global Outcomes (KDIGO) recommendation grading system
strength of recommendation
Level 1 ("we recommend") - most patients should receive recommended course of action
Level 2 ("we suggest") - different choices will be appropriate for different patients, based on patient's values and
preferences
Not Graded - topic does not allow adequate application of evidence, not meant to be interpreted as being stronger
recommendations than Level 1 or 2
quality of evidence
Grade A - high-quality evidence, true effect lies close to that of estimate of effect
Grade B - moderate-quality evidence, true effect likely to be close to estimate of effect, but there is a possibility it is
substantially different
Grade C - low-quality evidence, true effect may be substantially different from estimate of effect
Grade D - very low-quality evidence, estimate of effect very uncertain and often far from the truth
Reference - KDIGO clinical practice guideline on acute kidney injury (Kidney Inter Suppl 2012 Mar;2(1):1 PDF),
commentary can be found in Am J Kidney Dis 2013 May;61(5):649)
British Consensus Guidelines on Intravenous Therapy for Adult Surgery (GIFTASUP) uses Oxford Centre for Evidence Based
Medicine (CEBM) grading system for evidence and recommendations
levels of evidence
Level 1a - systematic review with homogeneity of randomized controlled trials (RCTs)
Level 1b - individual RCT with narrow confidence interval
Level 1c - all or none case series
Level 2a - systematic review with homogeneity of cohort studies
Level 2b - individual cohort study or low-quality RCT
Level 2c - "outcomes" research, ecological studies
Level 3a - systematic review with homogeneity of case-control studies
Level 3b - individual case-control study
Level 4 - case series, poor-quality cohort and case-control studies
Level 5 - expert opinion without explicit critical appraisal, or based on physiology, bench research, or "first principles"
grades of recommendation
Grade A - consistent level 1 studies
Grade B - consistent level 2 or 3 studies or extrapolations from level 1 studies
Grade C - level 4 studies or extrapolations from level 2 or 3 studies
Grade D - level 5 evidence or troublingly inconsistent or inconclusive studies of any level
Reference - British consensus guideline on intravenous fluidtherapy for adult surgical patients (GIFTASUP 2012 PDF)
DynaMed editorial process:

DynaMed topics are created and maintained by the DynaMed Editorial Team and Process.
All editorial team members and reviewers have declared that they have no financial or other competing interests related to
this topic, unless otherwise indicated.
DynaMed provides Practice-Changing DynaMed Updates, with support from our partners, McMaster University and F1000.
Special acknowledgements:
Constantine Manthous, MD (Staff Intensivist, Lawrence and Memorial Hospital & IPC; Connecticut, United States)
Dr. Manthous declares no relevant financial conflicts of interest.
Esther Jolanda van Zuuren, MD (Head of Allergy, Dermatology, and Venereology, Leiden University Medical Centre;
DynaMed 10/2/19 19'46
Netherlands; Editor, Cochrane Skin Group)

Dr. van Zuuren declares no relevant financial conflicts of interest.
Terence K. Trow, MD, FACP, FCCP (Deputy Editor of Pulmonary, Critical Care, and Sleep Medicine; Ex-Director of the Yale
Pulmonary Vascular Disease Program, Associate Clinical Professor of Medicine, Yale University School of Medicine;
Connecticut, United States)
Dr. Trow declares no relevant financial conflicts of interest.
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DynaMed 10/2/19 19'46

Fluid selection for IV fluid resuscitation

Esther Jolanda van Zuuren, MD

Terence K. Trow, MD, FACP, FCCP

compared to crystalloid or albumin in patients with sepsis

recent evidence has changed understanding of this fluid dynamic

Crystalloids as first choice for resuscitation:

Type and Composition of Crystalloid Resuscitation Fluids(1, 2, 3):

Solution Osmolarity pH Sodium Chloride Potassium Calcium Magnesium Lactate Acetate

Ringer 310 6 147 155 4 mmol/L 4 0 mmol/L 0 mmol/L 0 mmol/L

Ringer 276 6-8 130 112 5 mmol/L 1 1 mmol/L 0 mmol/L 27

Hartmann 278 5-7 131 111 5 mmol/L 2 0 mmol/L 29 mmol/L 0 mmol/L

Plasma- 294 4-8 140 98 5 mmol/L 0 3 mmol/L 0 mmol/L 27

Comparative efficacy of different crystalloids:

3% HSS 7.5% HSS Lactated Ringer

infusion volume in 1 hour 1.1 L* 1 L* 2.1 L

Abbreviations: HSS, hypertonic saline solution.

*p < 0.05 vs. Lactated Ringer

†data estimated from figure

Complications 3% HSS 7.5% HSS Lactated Ringer

Acute renal failure 0% 0% 6%*#

Pulmonary edema 0% 0% 5%*#

Transient hypotension 0% 5%* 0%

Abbreviations: HSS, hypertonic saline solution.

*p < 0.05 among groups (pairwise comparisons not reported)

#p < 0.001 vs. HSS groups

Type and Composition of Colloid Resuscitation Fluids(1, 2, 3):

Solution* Osmolarity Sodium Chloride Oncotic Half Life

Albumins 5% Albumin 309 mOsm/L 145 mmol/L 145 mmol/L 20 mm Hg 20 days

HES 6% HES 130/0.4 286-308 137-154 mmol/L 110-154 mmol/L 36 mm Hg 12 hours

Gelatin 4% succinylated 274 mOsm/L 154 mmol/L 120 mmol/L NA NA

3.5% urea- 301 mOsm/L 154 mmol/L 154 mmol/L NA NA

Abbreviations: HES, hydroxyethyl starches; NA, not applicable.

*different commercially available brands may vary in composition

dialysis-dependent renal failure, or evidence of intracranial hemorrhage on computed tomography

based on Cochrane review with incomplete assessment of trial quality

United States guidelines:

United Kingdom guidelines:

Australian and New Zealand guidelines:

General references used:

Recommendation grading systems used:

DynaMed editorial process:

Netherlands; Editor, Cochrane Skin Group)

Please give us your feedback by e-mailing DynaMed at: DynaMedEditor@ebscohost.com

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