the role of balanced salt solutions in resuscitation

1. FLUIDS IN
NEUROPATHOLOGY
Pankaj anand

2. History & patient demographics
• 45 years old, Male patient presented to the
ED with the history of a car accident
• Polytrauma resulting from car crash against
truck
• Weight of the patient is 68 kg

3. • On presentation, the patient was bleeding
profusely
• Patient presented with altered consciousness
and injury
• On preliminary history, he was Diabetic, non
hypertensive, no other reported comorbidities
or allergies

4. Examination
• Vitals
– HR 145/min
– BP 74/40 mmHg
– Afebrile
– Blood oxygen level (SpO2) 92% on room air

5. • Physical examination
– Respirations are rapid
– Skin is cold and clammy
– Patient was disoriented to time, place & person

6. Investigations
• Laboratory Investigations
– Haemoglobin (HB) 6.1 mg/ dL; Haematocrit 22 %
– International normalized ratio (INR) 1.6,
– Arterial blood gases (ABG) parameters: pH 7.12,
paCO2 -51 mmHg, paO2 -87 mmHg,
– HCO3 : 20.1 mmol/L
– Na+ 132 mmol/L, Cl- 108 mmol/L, K+ - 3.4 mmol/L,
Glucose - 284 mg/dL, Lactate - 8.6 mmol/L

7. Investigations
• The patient had #Left Femur (open), Left Humerus(closed),
and Left Maxilla fracture
• CT C-spine was normal as well as D-L Spine
• Ultrasound showed no free fluid in the abdominal cavity( E-
FAST Negative )
• Chest X-ray revealed No Fractures and any significant
abnormality
• Brain NCCT showed Mild SAH ( Fisher Grade 2 ) with
bleeding into the right ventricle.

8. Primary treatment
• The primary resuscitation is initialized through the administration
of 3500 mL Normal saline(0.9%) and Two units of PRBC
• Patient requires Inotropic support for Blood Pressure maintenance.
• After external immobilization of the left femur, the patient was
immediately taken to the operation theater for Femur fracture
reduction and stabilisation.
• After the 3 hours of surgery ( under GA )patient was shifted to the
ICU for further care with ET in situ ( Intra- op NS is continued )

9. Further course of management
• The various parameters in ICU were as per below
– Haemoglobin (Hb) 8.2 mg/ dL
– Arterial blood gases (ABG) parameters:
– pH 7.10
– HCO3-: 18.1 mmol/L
– Na+ 144 mmol/L, K+ 5.9 mmol/L
– Chloride: 118 mmol/L
– Lactate : 4.5 mmol/L

10. Further course of management
• Volume resuscitation with one more unit PRBC
is continued
• Patient had U/O ~ 20-25 ml/hr initially post-
Surgery which improved gradually within 8-10
hours of further resuscitation with NS @
125ml/hr.
• Hemoglobin stabilised at 9.7mg/dl.

11. Further course of management
• Gradually Hemodynamic parameters improved
with downtrend of ionotropic support.
• In the ICU the patient was mechanically
ventilated following the corresponding
parameters and clinically monitored continuously
• After 2 days in ICU, the patient showed
improvement on biochemical parameters.
• Repeat NCCT head reveals no Increase in Bleed
size.
• On day 3 weaning was initiated, and patient was
extubated.

12. Important points with respect to fluid
therapy & choice of fluid
• Impact of normal saline
• Benefits that might have incurred by changing
to the balanced salt solution
• Chances of acute kidney injury with the use of
large volume of normal saline superimposed
by hypovolemic shock induced kidney damage

13. Introduction
Management of neurosurgical patients differ
due to following pathophysiological processes:
• Cerebral Oedema formation
• Increased intracranial pressure
• Low hypoxic tolerance

14. Introduction
• Fluid management in critically ill brain injured
patients is aimed at maintaining adequate
cerebral blood flow (CBF) and oxygenation.
• Cerebral Perfusion Pressure (CPP) is of utmost
importance.[MAP-ICP]

16. Tonicity
• Normal
Osmolality : Plasma = Brain Interstitial Fluid
• BBB Disruption
Abolishes Homeostasis
Electrolytes/water/solutes
Hypotonic Fluids cause water shift to Brain
Hypertonic Fluids cause the opposite

17. Oedema
• Cytotoxic oedema
Cellular oedema of neurons or astrocytes
Mitochondrial disruption-ATP Depletion
Sodium and water shifts into cells
• Vasogenic oedema
Disrupted endothelial tight junctions
Both water and albumin shift
• Ionic oedema
Compensatory solute and water shifts between
vascular compartment and interstitium through
intact BBB

18. Natural
colloids
Artificial
colloids
e.g. 0.9 % NaCl
Ringer´s Lactate
Balanced Crystalloids
Colloids
Gelatin
Dextran
HES
Crystalloids
Albumin
Which type of fluids?

19. Characteristics of Various Fluids
Hoorn EJ. Intravenous fluids: balancing solutions [published correction
appears in J Nephrol. 2020 Apr;33(2):387]. J Nephrol. 2017;30(4):485-492.
doi:10.1007/s40620-016-0363-9

20. Colloids
• A large, multi-center trial, the Saline versus Albumin
Fluid Evaluation (SAFE) trial, found no difference in 28-
day mortality for critically ill patients resuscitated with
albumin(4%) versus saline.
• Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R; SAFE Study Investigators. A comparison of albumin and saline for
fluid resuscitation in the intensive care unit. N Engl J Med. 2004 May 27;350(22):2247-56. doi: 10.1056/NEJMoa040232. PMID:
15163774.
• But…
• A Subgroup analysis of SAFE participants suggested
an increased number of deaths among patients
with TBI who received albumin

21. Colloids
• To determine the potential significance of this finding,
the SAFE study investigators undertook a post-
hoc analysis (SAFE-TBI).
• Based on the results of SAFE-TBI the Cochrane group
concluded that there is No evidence from RCT in
critically ill or trauma patients that resuscitation with
colloids compared to crystalloids reduces the risk of
death.
• To explore the efficacy of albumin as a neuroprotective
agent for TBI in humans, a randomized controlled trial,
Albumin for Intracerebral Hemorrhage Intervention
(ACHIEVE), is currently underway.

22. Crystalloids
Hypo-Osmolar
• 0.45% saline or 5% glucose in water - cause a
concomitant reduction in plasma osmolality
and can cause cerebral edema.
• The osmotic gradient drives water across the
BBB into the cerebral tissue, increasing brain
water content (= edema) and ICP.
• Weed LH, McKibben PS. Pressure changes in the cerebrospinal fluid
following intravenous injection of solutions of various concentrations. Am
J Physiol 1919;48:512– 30.

23. Crystalloids
Hyper-Osmolar
• A relatively small volume (4 mL/kg) of hypertonic saline(3–7%)
can significantly reduce ICP, correct CBF and improve cerebral
oxygen delivery.
• Hypertonic saline also suppresses production of pro-
inflammatory cytokines in activated microglia and increases the
expression of inducible nitric oxide synthase in the peri-
ischaemic area.
• The CNS effects of hypertonic saline are similar to mannitol.
• Principal disadvantage of hypertonic saline is related to the
possible danger of hypernatremia.
• Another concern is that hypertonic saline solutions have the
potential to cause rebound intracranial hypertension.
Gemma M, Cozzi S, Tommasino C, et al. 7.5% hypertonic saline versus 20% mannitol during
elective neurosurgical supratentorial procedures. J Neurosurg Anesthesiol 1997;9:329 – 34

24. Crystalloids
Iso-Osmolar
• Iso-osmolar solutions, with an osmolality ~ 300 mOsm/L, such
as Plasmalyte, 0.9% saline, do not change plasma osmolality,
and do not increase brain water content.
• Same does not apply to solutions that are not truly iso-osmolar
with respect to plasma.
• Commercial lactated Ringer’s solution has a calculated
osmolarity of 275 mOsm/L, but a measured osmolality of 254
mOsm/kg, indicating incomplete dissociation.
• The administration of large volumes of RL(> 3 l in humans) can
reduce plasma osmolality and increase brain water content and
ICP, as approximately 114 mL of free water is given for each liter
of lactated Ringer’s solution.
Prough DS, Johnson JC, Poole GV, et al. Effects on intracranial pressure of resuscitation from
hemorrhagic shock with hypertonic saline vs lactated Ringer’s solution. Crit Care Med
1985;13:407–11.

25. Crystalloids
Iso-Osmolar
• Infusion of large volumes of normal saline commonly
leads to dilution hyperchloremic metabolic acidosis,
particularly in hypovolaemic patients with impaired
kidney function or perfusion.
• Massive infusion of chloride-rich fluids leads to renal
ischemia following interstitial oedema, and reduces
glomerular-filtration following arterial
vasoconstriction, hence increasing the risk of AKI
• Li H, Sun Sr, Yap JQ, et al. 0.9% saline is neither normal nor physiological.J Zhejiang Univ Sci B.
2016; 17(3): 181–187, doi: 10.1631/jzus.B1500201,indexed in Pubmed: 26984838
• Infusion of 20 mL/kg of chloride solution (9 L of 0.9% NaCl)
decreases base excess by 10 mmol/L in a typical 70 kg
patient

26. Role of Balanced Salt Solution
• Isotonic balanced salt solutions reduce the occurrence of
dilution hyperchloremic acidosis and do not affect ICP and the
number of episodes of intra-cranial hypertension (ICH)
Roquilly A, Loutrel O, Cinotti R, et al. Balanced versus chloride-rich solutions for fluid resuscitation in brain-injured patients:
a randomised double-blind pilot study. Crit Care. 2013; 17(2): R77, doi: 10.1186/cc12686, indexed in Pubmed: 23601796.
• Despite their different composition, some authors have documented similar
unfavourable effects of Plasma-LyteR and 0.9% NaCl on kidney function in 12
healthy volunteers.
Chowdhury AH, et al. A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline
and plasma-lyteR 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers. Ann Surg. 2012;
256(1): 18–24,
• Although both fluids expanded the intravascular volume to the same degree,
extravascular fluid disorders were significantly greater in the 0.9% NaCl compared
to the Plasma-LyteR group.

27. • Year of study- 2017
• Total 66 patients- Severe TBI who required emergency craniotomy
selected
• Divided into NS(33) and BF(33) groups
• Maintenance fluid given as per Holliday-Segar method
• Electrolyte and Acid-base parameters accessed at 8hour intervals for total
24hours.

28. Findings
• NS group showed a significantly lower base excess and lower
bicarbonate levels.
• NS group showed more hyperchloremia and hypokalemia as
compared to BF group.
• The BF group showed a significantly higher level of calcium and
magnesium than the NS group.
• No significant differences were found in pH, pCO2, lactate, and
sodium level.
Conclusion
• BF therapy showed better effects in maintaining higher electrolyte
parameters and reducing the trend toward hyperchloremic metabolic
acidosis than the NS therapy during prolonged fluid therapy for
postoperative TBI patients.

29. Balanced Crystalloids Versus Saline for Perioperative
Intravenous Fluid Administration in Children
Undergoing Neurosurgery
• 53 patients (age range, 6mo to 12 y) were randomized to receive balanced
crystalloid (balanced group) or 0.9% saline solution (saline group) during and after
(for 24 h) brain tumor resection.
• The primary trial outcome was the absolute difference in serum chloride
concentrations measured after surgery and at baseline.
• Secondary outcomes included the variations in other electrolytes and base excess
(BE); hyperchloremic acidosis incidence; and the brain relaxation score, a 4-point
scale evaluated by the surgeon for assessing brain edema.
• In children undergoing craniotomy for brain tumor resection, saline infusion
resulted in increased serum chloride variation from before to after surgery.
Balanced crystalloid was associated with a safer electrolyte and acid-base profile
compared with the use of saline.
Lima et al, Balanced Crystalloids Versus Saline for Perioperative Intravenous Fluid Administration in Children
Undergoing Neurosurgery: A Randomized Clinical Trial, Journal of Neurosurgical Anesthesiology: January
2019 - Volume 31 - Issue 1 - p 30-35 doi: 10.1097/ANA.0000000000000515

30. AHA/ASA guidelines for the
early management of patients with
acute ischaemic stroke (2013)
• Daily fluid maintenance for adults estimated as 30
ml/kg body weight
• Use isotonic fluids rather than hypotonic fluids
(might exacerbate ischaemic brain oedema)
• Hypovolemia should be corrected with i.v. normal
saline

31. AHA/ASA Recommendations for
the management of cerebral and
cerebellar infarction with swelling(2014)
• Use of adequate fluid administration with isotonic
fluids might be considered.
(Class IIb,evidence level C)
• Hypotonic or hypo-osmolar fluids are not
recommended. (Class III, evidence level C)
• Wijdicks EF,et al.Recommendations for the management of cerebral and cerebellar
infarction with swelling: a statement for healthcare professionals from the American
Heart Association/American Stroke Association. Stroke. 2014;45(4):1222–38.

32. Guidelines for the Management of
Severe Traumatic Brain Injury,
Fourth Edition(2016)
• No specifications for any particular fluid

33. THANK YOU