Three sentences:
The document summarizes evidence from studies comparing normal saline to balanced crystalloid solutions like Ringer's lactate for intravenous fluid therapy. Large randomized controlled trials found balanced crystalloids were associated with fewer kidney complications compared to normal saline, especially in critically ill patients. More recent studies found no significant differences in outcomes between fluid types when administered at different rates, suggesting volume may be a more important factor than specific fluid used.
- IV fluids can be either beneficial or harmful depending on how they are administered. The optimal volume and type of fluid needs to be determined based on the individual patient's condition, fluid losses, and volume status. While crystalloids are generally preferred over colloids, aggressive fluid resuscitation is important for conditions like burns, trauma, and sepsis. Close monitoring of fluid administration and outcomes is essential to avoid under- or over-hydration.
This document provides information on fluid therapy. It begins by classifying fluids as crystalloids or colloids based on their ability to diffuse. Crystalloids like normal saline (NS) diffuse freely while colloids do not pass as readily. NS is commonly used but can cause acidosis due to its chloride content. Ringer's lactate is more physiological with an electrolyte profile similar to plasma. Dextrose solutions like 5% dextrose provide calories but can increase lactate levels in critical illness. The document discusses the properties, indications, and limitations of various intravenous fluids.
Iv fluid therapy (types, indications, doses calculation)kholeif
Intravenous fluid therapy is essential for maintaining normal body functioning and hydration. There are three main types of intravenous fluids - colloids, crystalloids, and blood products. Crystalloids include isotonic fluids like 0.9% sodium chloride and lactated Ringer's solution, hypotonic fluids, and hypertonic fluids. Isotonic fluids maintain intravascular volume while hypotonic and hypertonic fluids shift fluid between intravascular and intracellular spaces. Close monitoring is needed with intravenous fluid therapy to avoid complications of overhydration or dehydration.
differences & indications of ringers (solution/buffered with lactate & acetate) Vs Normal saline in different medical conditions
Presented as lecture at 25th.July 2022
The document discusses water and electrolyte balance, which is important for homeostasis. The kidney plays a key role in maintaining circulating volume, osmolality, and electrolyte balance. Fluid volume and electrolyte composition can change pre, intra, and postoperatively due to factors like trauma or sepsis. Total body water is about 60% of body weight, with two thirds being intracellular fluid and one third extracellular fluid including plasma and interstitial fluid. Key electrolytes include sodium, potassium, calcium, and proteins. Precise fluid management is important during the pre, intra, and postoperative periods.
This document discusses fluid therapy and body fluid compartments. It covers the following key points:
1) The human body contains two main fluid compartments - intracellular fluid (ICF) and extracellular fluid (ECF). ECF is further divided into interstitial fluid, intravascular fluid, and transcellular fluid.
2) Fluid movement between compartments is governed by diffusion, osmosis, osmolality, tonicity, and oncotic pressure. Renal, neuroendocrine, and other physiological systems help regulate fluid balance.
3) Perioperative fluid needs include maintenance requirements, replacing deficits from fasting or losses, accounting for third spacing of fluids, and replacing blood loss.
This document discusses fluid management in the ICU. It covers assessing volume status through history, exam, and tests. Common types of IV fluids are described including crystalloids like normal saline and lactated Ringer's, as well as colloids like albumin and HES. Normal saline can cause hyperchloremic acidosis while HES is no longer recommended due to safety concerns. Guidelines for fluid resuscitation in hypovolemia and septic shock are provided, emphasizing initial bolus volumes and ongoing reassessment. In general, balanced crystalloids are preferred to normal saline due to safety advantages.
This document discusses perioperative fluid therapy. It covers topics such as total body water, fluid compartments, preoperative fluid status evaluation, intravenous fluids including crystalloids like normal saline and lactated ringer's solution and colloids like albumin, gelatin and hydroxyethyl starches. It provides guidelines on calculating fluid requirements including maintenance fluids, deficits, third spacing losses and blood loss replacement. The document emphasizes using crystalloids over colloids for resuscitation and limiting colloid volumes due to lack of evidence for their continued use in acute illness.
- IV fluids can be either beneficial or harmful depending on how they are administered. The optimal volume and type of fluid needs to be determined based on the individual patient's condition, fluid losses, and volume status. While crystalloids are generally preferred over colloids, aggressive fluid resuscitation is important for conditions like burns, trauma, and sepsis. Close monitoring of fluid administration and outcomes is essential to avoid under- or over-hydration.
This document provides information on fluid therapy. It begins by classifying fluids as crystalloids or colloids based on their ability to diffuse. Crystalloids like normal saline (NS) diffuse freely while colloids do not pass as readily. NS is commonly used but can cause acidosis due to its chloride content. Ringer's lactate is more physiological with an electrolyte profile similar to plasma. Dextrose solutions like 5% dextrose provide calories but can increase lactate levels in critical illness. The document discusses the properties, indications, and limitations of various intravenous fluids.
Iv fluid therapy (types, indications, doses calculation)kholeif
Intravenous fluid therapy is essential for maintaining normal body functioning and hydration. There are three main types of intravenous fluids - colloids, crystalloids, and blood products. Crystalloids include isotonic fluids like 0.9% sodium chloride and lactated Ringer's solution, hypotonic fluids, and hypertonic fluids. Isotonic fluids maintain intravascular volume while hypotonic and hypertonic fluids shift fluid between intravascular and intracellular spaces. Close monitoring is needed with intravenous fluid therapy to avoid complications of overhydration or dehydration.
differences & indications of ringers (solution/buffered with lactate & acetate) Vs Normal saline in different medical conditions
Presented as lecture at 25th.July 2022
The document discusses water and electrolyte balance, which is important for homeostasis. The kidney plays a key role in maintaining circulating volume, osmolality, and electrolyte balance. Fluid volume and electrolyte composition can change pre, intra, and postoperatively due to factors like trauma or sepsis. Total body water is about 60% of body weight, with two thirds being intracellular fluid and one third extracellular fluid including plasma and interstitial fluid. Key electrolytes include sodium, potassium, calcium, and proteins. Precise fluid management is important during the pre, intra, and postoperative periods.
This document discusses fluid therapy and body fluid compartments. It covers the following key points:
1) The human body contains two main fluid compartments - intracellular fluid (ICF) and extracellular fluid (ECF). ECF is further divided into interstitial fluid, intravascular fluid, and transcellular fluid.
2) Fluid movement between compartments is governed by diffusion, osmosis, osmolality, tonicity, and oncotic pressure. Renal, neuroendocrine, and other physiological systems help regulate fluid balance.
3) Perioperative fluid needs include maintenance requirements, replacing deficits from fasting or losses, accounting for third spacing of fluids, and replacing blood loss.
This document discusses fluid management in the ICU. It covers assessing volume status through history, exam, and tests. Common types of IV fluids are described including crystalloids like normal saline and lactated Ringer's, as well as colloids like albumin and HES. Normal saline can cause hyperchloremic acidosis while HES is no longer recommended due to safety concerns. Guidelines for fluid resuscitation in hypovolemia and septic shock are provided, emphasizing initial bolus volumes and ongoing reassessment. In general, balanced crystalloids are preferred to normal saline due to safety advantages.
This document discusses perioperative fluid therapy. It covers topics such as total body water, fluid compartments, preoperative fluid status evaluation, intravenous fluids including crystalloids like normal saline and lactated ringer's solution and colloids like albumin, gelatin and hydroxyethyl starches. It provides guidelines on calculating fluid requirements including maintenance fluids, deficits, third spacing losses and blood loss replacement. The document emphasizes using crystalloids over colloids for resuscitation and limiting colloid volumes due to lack of evidence for their continued use in acute illness.
Fluid management in the paediatric patient anaesthetist consideration...drriyas03
This document discusses fluid management in paediatric patients. It covers water physiology and fluid compartments in the body. Fluid volumes change with age from premature neonates to adults. Daily fluid losses are outlined. Methods for determining fluid requirements and correcting dehydration are presented. Intraoperative fluid replacement depends on the type and severity of surgery. Blood loss and transfusion thresholds are addressed. Selection of intravenous fluids must be tailored to the individual patient's needs.
1. Ringers lactate is the most physiological intravenous fluid. Isotonic saline and DNS have the highest sodium content while isotonic saline, DNS, and ISO-G have the highest chloride levels.
2. Isolyte-G is the only intravenous fluid that can directly correct metabolic alkalosis. Isolyte-M, P, G, and E along with Ringer's lactate should generally be avoided in patients with renal failure.
3. Ringer's lactate, isotonic saline, and 5% dextrose are preferred for diabetic patients as they do not contain glucose. NS, DNS, and dextrose solutions do not contain potassium and do not directly correct acid-
This document discusses inotropes, which are drugs that increase the force of myocardial contraction. It defines inotropes and discusses their physiological effects and classification. Various endogenous and exogenous inotropic agents are described in detail, including their mechanisms of action, indications, dosages, pharmacokinetics and side effects. Sympathomimetic drugs like epinephrine, norepinephrine and dopamine are discussed as conventional positive inotropic agents.
colloids with their properties and their benefits and disadvantages . indications for colloids. types of colloids and their effect on volume expansio.various studies done for colloids. body fluid compartments and distribution of total body water.
Intravenous fluids crystalloids and colloidsomar143
Dr. Omar Kamal Ansari from the department of anaesthesiology discusses intravenous fluid therapy. He describes various types of intravenous fluids including crystalloids like normal saline and Ringer's lactate, colloids like albumin and hetastarch, and discusses their indications, contraindications, and complications. He also discusses fluid requirements, osmolality, electrolyte balances, and principles of intravenous fluid administration.
This document summarizes information about using sodium bicarbonate (NaHCO3) to treat acidosis. It discusses what bicarbonate is, how it works to neutralize acid in the blood, appropriate dosing, administration, safety issues, and contraindications. It specifically examines using bicarbonate to treat diabetic ketoacidosis (DKA) and lactic acidosis, noting that the evidence does not clearly support its routine use in DKA but it may be considered in severe cases with pH <6.9. For lactic acidosis, bicarbonate may help if pH is <7.1 but the evidence is limited and it could increase lactate levels and mortality. The
Fluid management is a major part of hospital activity and peri-operative care. It is essential to understand fluid physiology and the compositions of different fluids prescribed in order to properly manage a patient's fluid balance. Regular assessment of the patient's clinical status is needed to determine fluid needs and ensure fluids are appropriately prescribed for resuscitation, maintenance, or replacement purposes.
This document summarizes different types of colloid solutions that can be used for fluid resuscitation, including their properties and results from clinical trials comparing colloids to crystalloids. It discusses natural and synthetic colloids such as albumin, gelatin, starch, and dextran. For starch solutions, it describes concentration, molecular weight, degree of substitution, and C2:C6 ratio. It summarizes trials finding increased risks of death and kidney injury with some hydroxyethyl starches. Overall, the document recommends crystalloids as the initial fluid of choice in sepsis and considering albumin for large volume resuscitation, but against the use of some hydroxyethyl starches.
Fluid Therapy is the administration of fluids to a patient as a treatment or preventative measure. It can be administered via an intravenous, intraperitoneal, intraosseous, subcutaneous and oral routes. 60% of total bodyweight is accounted for by the total body water.
Different fluids can be
cyrstalloids, colloids, hypertonic saline, hypotonic saline, ringer lactate.
This document discusses potassium homeostasis and hyperkalemia. It notes that potassium is mainly intracellular and its serum level is tightly regulated between 3.5-5 mEq/L. Mechanisms involve sodium-potassium pumps and renal excretion. Causes of hyperkalemia include reduced renal excretion, intracellular shifts, and inadequate aldosterone levels. Symptoms range from none to muscle weakness to arrhythmias. Treatment focuses on antagonizing cardiac effects, driving potassium intracellularly, and removing excess potassium.
This document outlines the steps to calculate sodium correction for hypo- and hypernatremia. For hyponatremia, it describes how to determine: 1) the change in serum sodium per liter of infusate, 2) the volume required, 3) the time required for correction, and 4) the infusion rate. For hypernatremia, the same steps are followed to calculate water deficit and rate of correction using free water. An example for each is provided to demonstrate the full calculation.
Dr. Vijay Kumar discusses fluid management in the emergency department and intensive care unit. He covers the normal regulation of fluid balance, fluid imbalances that can occur in shock states, and indices used to assess successful fluid resuscitation. Both under-resuscitation and overzealous fluid administration can increase patient morbidity and mortality, so fluid therapy must be carefully titrated based on close monitoring of the patient's hemodynamic status and tissue perfusion.
1) The document discusses fluid management, summarizing water intake and output in the human body and types of intravenous fluids used.
2) It provides details on crystalloid and colloid solutions, as well as the composition of commonly used crystalloids.
3) Preferred intravenous fluids for different conditions are outlined, along with fluid regimen calculations and management of electrolyte imbalances that can occur during surgery.
This document summarizes the history of fluid resuscitation and discusses various resuscitation fluids. It describes the ideal properties of a resuscitation fluid and notes that currently no single fluid exists that meets all criteria. Several types of colloid and crystalloid fluids are discussed, along with major studies investigating their safety and efficacy in different patient populations. The document concludes that isotonic crystalloids are generally appropriate for initial resuscitation, and that specific considerations apply to fluid selection for different categories of patients such as those with sepsis, traumatic brain injury, or burns.
Balanced solution is a boon for fluid resuscitationdr nirmal jaiswal
Balanced crystalloids are emerging as the fluid of choice for resuscitation over normal saline. Normal saline can cause hyperchloremic acidosis due to its high chloride content. Balanced crystalloids more closely mimic the electrolyte composition of plasma. Studies show balanced crystalloids may reduce complications like renal injury and need for renal replacement therapy compared to normal saline in critically ill patients. The optimal fluid choice depends on factors like the patient's clinical condition, electrolyte levels, and volume needed.
by the renowned pediatrician, Dr Satish Deopujari,
National Chairperson (Ex)
Intensive Care Chapter I A P
Founder Chairman.....
National conference on pediatric critical care
Professor of pediatrics ( Hon ) JNMC:Wardha
Nagpur : INDIA
The term inotropic state is most commonly used in reference to various drugs that affect the strength of contraction of heart muscle (myocardial contractility). However, it can also refer to pathological conditions. For example, enlarged heart muscle (ventricular hypertrophy) can increase inotropic state, whereas dead heart muscle (myocardial infarction) can decrease it.
This document presents an agenda and content for a lecture on fluid management in acute kidney injury (AKI). The agenda covers definitions and causes of AKI, classification, epidemiology, prognosis, treatment principles including the role of loop diuretics, fluid balance, selection of resuscitation fluids, and fluid overload in AKI and its mechanisms. Key points include that AKI is defined as a rise in serum creatinine or BUN, and has three categories: pre-renal, intrinsic, and post-renal. The prognosis and mortality rate for AKI depends on the cause and presence of other organ dysfunction. Treatment aims to maintain volume homeostasis and correction of biochemical abnormalities.
Crystalloids are electrolyte solutions that can freely diffuse throughout the extracellular space. The principal crystalloid is isotonic saline (0.9% NaCl), which expands the interstitial space rather than plasma volume. Ringer's lactate is also commonly used as it more closely matches plasma composition. Dextrose 5% in water (D5W) is hypotonic and expands both intra and extracellular spaces, providing calories but not electrolytes. Each crystalloid has different indications and disadvantages to consider when selecting the appropriate fluid for treatment.
1) AKI is defined as an increase in serum creatinine within 48 hours or 1.5 times baseline within 7 days, or urine output less than 0.5 ml/kg/h for 6 hours. Prevention focuses on optimizing volume status, limiting nephrotoxic medications, and hydration for procedures requiring contrast.
2) Secondary prevention of AKI aims to avoid further injury, facilitate recovery, and prevent complications. For rhabdomyolysis, aggressive hydration and bicarbonate are recommended to prevent myoglobin precipitation in tubules. Fluid management must be monitored to avoid electrolyte abnormalities.
Fluid management in the paediatric patient anaesthetist consideration...drriyas03
This document discusses fluid management in paediatric patients. It covers water physiology and fluid compartments in the body. Fluid volumes change with age from premature neonates to adults. Daily fluid losses are outlined. Methods for determining fluid requirements and correcting dehydration are presented. Intraoperative fluid replacement depends on the type and severity of surgery. Blood loss and transfusion thresholds are addressed. Selection of intravenous fluids must be tailored to the individual patient's needs.
1. Ringers lactate is the most physiological intravenous fluid. Isotonic saline and DNS have the highest sodium content while isotonic saline, DNS, and ISO-G have the highest chloride levels.
2. Isolyte-G is the only intravenous fluid that can directly correct metabolic alkalosis. Isolyte-M, P, G, and E along with Ringer's lactate should generally be avoided in patients with renal failure.
3. Ringer's lactate, isotonic saline, and 5% dextrose are preferred for diabetic patients as they do not contain glucose. NS, DNS, and dextrose solutions do not contain potassium and do not directly correct acid-
This document discusses inotropes, which are drugs that increase the force of myocardial contraction. It defines inotropes and discusses their physiological effects and classification. Various endogenous and exogenous inotropic agents are described in detail, including their mechanisms of action, indications, dosages, pharmacokinetics and side effects. Sympathomimetic drugs like epinephrine, norepinephrine and dopamine are discussed as conventional positive inotropic agents.
colloids with their properties and their benefits and disadvantages . indications for colloids. types of colloids and their effect on volume expansio.various studies done for colloids. body fluid compartments and distribution of total body water.
Intravenous fluids crystalloids and colloidsomar143
Dr. Omar Kamal Ansari from the department of anaesthesiology discusses intravenous fluid therapy. He describes various types of intravenous fluids including crystalloids like normal saline and Ringer's lactate, colloids like albumin and hetastarch, and discusses their indications, contraindications, and complications. He also discusses fluid requirements, osmolality, electrolyte balances, and principles of intravenous fluid administration.
This document summarizes information about using sodium bicarbonate (NaHCO3) to treat acidosis. It discusses what bicarbonate is, how it works to neutralize acid in the blood, appropriate dosing, administration, safety issues, and contraindications. It specifically examines using bicarbonate to treat diabetic ketoacidosis (DKA) and lactic acidosis, noting that the evidence does not clearly support its routine use in DKA but it may be considered in severe cases with pH <6.9. For lactic acidosis, bicarbonate may help if pH is <7.1 but the evidence is limited and it could increase lactate levels and mortality. The
Fluid management is a major part of hospital activity and peri-operative care. It is essential to understand fluid physiology and the compositions of different fluids prescribed in order to properly manage a patient's fluid balance. Regular assessment of the patient's clinical status is needed to determine fluid needs and ensure fluids are appropriately prescribed for resuscitation, maintenance, or replacement purposes.
This document summarizes different types of colloid solutions that can be used for fluid resuscitation, including their properties and results from clinical trials comparing colloids to crystalloids. It discusses natural and synthetic colloids such as albumin, gelatin, starch, and dextran. For starch solutions, it describes concentration, molecular weight, degree of substitution, and C2:C6 ratio. It summarizes trials finding increased risks of death and kidney injury with some hydroxyethyl starches. Overall, the document recommends crystalloids as the initial fluid of choice in sepsis and considering albumin for large volume resuscitation, but against the use of some hydroxyethyl starches.
Fluid Therapy is the administration of fluids to a patient as a treatment or preventative measure. It can be administered via an intravenous, intraperitoneal, intraosseous, subcutaneous and oral routes. 60% of total bodyweight is accounted for by the total body water.
Different fluids can be
cyrstalloids, colloids, hypertonic saline, hypotonic saline, ringer lactate.
This document discusses potassium homeostasis and hyperkalemia. It notes that potassium is mainly intracellular and its serum level is tightly regulated between 3.5-5 mEq/L. Mechanisms involve sodium-potassium pumps and renal excretion. Causes of hyperkalemia include reduced renal excretion, intracellular shifts, and inadequate aldosterone levels. Symptoms range from none to muscle weakness to arrhythmias. Treatment focuses on antagonizing cardiac effects, driving potassium intracellularly, and removing excess potassium.
This document outlines the steps to calculate sodium correction for hypo- and hypernatremia. For hyponatremia, it describes how to determine: 1) the change in serum sodium per liter of infusate, 2) the volume required, 3) the time required for correction, and 4) the infusion rate. For hypernatremia, the same steps are followed to calculate water deficit and rate of correction using free water. An example for each is provided to demonstrate the full calculation.
Dr. Vijay Kumar discusses fluid management in the emergency department and intensive care unit. He covers the normal regulation of fluid balance, fluid imbalances that can occur in shock states, and indices used to assess successful fluid resuscitation. Both under-resuscitation and overzealous fluid administration can increase patient morbidity and mortality, so fluid therapy must be carefully titrated based on close monitoring of the patient's hemodynamic status and tissue perfusion.
1) The document discusses fluid management, summarizing water intake and output in the human body and types of intravenous fluids used.
2) It provides details on crystalloid and colloid solutions, as well as the composition of commonly used crystalloids.
3) Preferred intravenous fluids for different conditions are outlined, along with fluid regimen calculations and management of electrolyte imbalances that can occur during surgery.
This document summarizes the history of fluid resuscitation and discusses various resuscitation fluids. It describes the ideal properties of a resuscitation fluid and notes that currently no single fluid exists that meets all criteria. Several types of colloid and crystalloid fluids are discussed, along with major studies investigating their safety and efficacy in different patient populations. The document concludes that isotonic crystalloids are generally appropriate for initial resuscitation, and that specific considerations apply to fluid selection for different categories of patients such as those with sepsis, traumatic brain injury, or burns.
Balanced solution is a boon for fluid resuscitationdr nirmal jaiswal
Balanced crystalloids are emerging as the fluid of choice for resuscitation over normal saline. Normal saline can cause hyperchloremic acidosis due to its high chloride content. Balanced crystalloids more closely mimic the electrolyte composition of plasma. Studies show balanced crystalloids may reduce complications like renal injury and need for renal replacement therapy compared to normal saline in critically ill patients. The optimal fluid choice depends on factors like the patient's clinical condition, electrolyte levels, and volume needed.
by the renowned pediatrician, Dr Satish Deopujari,
National Chairperson (Ex)
Intensive Care Chapter I A P
Founder Chairman.....
National conference on pediatric critical care
Professor of pediatrics ( Hon ) JNMC:Wardha
Nagpur : INDIA
The term inotropic state is most commonly used in reference to various drugs that affect the strength of contraction of heart muscle (myocardial contractility). However, it can also refer to pathological conditions. For example, enlarged heart muscle (ventricular hypertrophy) can increase inotropic state, whereas dead heart muscle (myocardial infarction) can decrease it.
This document presents an agenda and content for a lecture on fluid management in acute kidney injury (AKI). The agenda covers definitions and causes of AKI, classification, epidemiology, prognosis, treatment principles including the role of loop diuretics, fluid balance, selection of resuscitation fluids, and fluid overload in AKI and its mechanisms. Key points include that AKI is defined as a rise in serum creatinine or BUN, and has three categories: pre-renal, intrinsic, and post-renal. The prognosis and mortality rate for AKI depends on the cause and presence of other organ dysfunction. Treatment aims to maintain volume homeostasis and correction of biochemical abnormalities.
Crystalloids are electrolyte solutions that can freely diffuse throughout the extracellular space. The principal crystalloid is isotonic saline (0.9% NaCl), which expands the interstitial space rather than plasma volume. Ringer's lactate is also commonly used as it more closely matches plasma composition. Dextrose 5% in water (D5W) is hypotonic and expands both intra and extracellular spaces, providing calories but not electrolytes. Each crystalloid has different indications and disadvantages to consider when selecting the appropriate fluid for treatment.
1) AKI is defined as an increase in serum creatinine within 48 hours or 1.5 times baseline within 7 days, or urine output less than 0.5 ml/kg/h for 6 hours. Prevention focuses on optimizing volume status, limiting nephrotoxic medications, and hydration for procedures requiring contrast.
2) Secondary prevention of AKI aims to avoid further injury, facilitate recovery, and prevent complications. For rhabdomyolysis, aggressive hydration and bicarbonate are recommended to prevent myoglobin precipitation in tubules. Fluid management must be monitored to avoid electrolyte abnormalities.
This document discusses fluid and electrolyte balance. It begins by outlining the objectives of reviewing normal fluid composition, crystalloid and colloid solutions, and perioperative fluid management. It then discusses the fluid compartments in the body, fluid homeostasis, types of fluids including crystalloids, colloids, and blood products. It provides details on specific crystalloid and colloid solutions, perioperative fluid therapy including maintenance requirements and replacing losses. It concludes by discussing clinical evaluation of fluid replacement and management of common electrolyte imbalances such as sodium, potassium, and calcium.
This document provides an overview and discussion of recent literature on renal replacement therapy (RRT) in intensive care. It summarizes key findings from two important studies from 2008 and 2009 that compared higher vs lower intensity RRT and found no difference in outcomes. It also discusses ongoing questions around optimal timing of RRT initiation and potential roles of biomarkers like NGAL. Modes of RRT like SLED are presented as alternatives to CRRT. While high volume hemofiltration was theorized to help modulate the immune response in sepsis, studies found no clear benefit and it cannot be recommended as standard practice. Ongoing research on biomarkers and optimal dosing and timing is still needed.
1) Acute kidney injury commonly occurs in critical illness and is a predictor of adverse outcomes. Common causes include renal hypoperfusion, SIRS, nephrotoxic drugs, and contrast nephropathy.
2) Early volume expansion is recommended to correct extracellular volume depletion, though certain colloids may impair renal function. Diuretics do not improve outcomes and increase side effects.
3) Maintaining an MAP of at least 60-65mmHg with vasopressors is recommended, and vasodilators like fenoldopam may benefit renal function. Tight glycemic control may reduce acute kidney injury in surgical ICU patients.
Balanced crystalloids were compared to saline for intravenous fluid administration in critically ill adults. The study involved over 15,000 patients randomized to receive either balanced crystalloids or saline. The primary outcome was a composite of death, new renal replacement therapy, or persistent renal dysfunction within 30 days. Fewer patients who received balanced crystalloids developed hyperchloremia or acidosis. The use of balanced crystalloids resulted in a 1.1 percentage point lower rate of reaching the primary outcome compared to saline.
This document discusses fluid management in acute pancreatitis. It begins by introducing acute pancreatitis and noting its potential severity. It then discusses the pancreatic microcirculation and how microcirculatory derangement occurs in acute pancreatitis, leading to edema, ischemia and necrosis. Several theories for these microcirculatory disturbances are presented. The rationale for fluid resuscitation to correct third spacing of fluid and increase tissue perfusion is explained. Guidelines are provided on which patients require fluid resuscitation and choices of fluid, including benefits of colloids over crystalloids and vice versa. Parameters for volume and rate of fluid resuscitation are outlined as well as goals for resuscitation monitoring.
Balanced fluid therapy aims to strike the right balance in fluid choice and administration. While 0.9% saline was traditionally used, it is not physiologically balanced and can lead to issues like hyperchloremic acidosis. Balanced crystalloid solutions like Plasma-Lyte and Ringer's lactate better match the electrolyte composition of blood and have shown benefits over saline in clinical studies, with reduced complications and lower mortality in critically ill patients. Large trials like SMART and SALT-ED found balanced fluids reduced major kidney adverse events compared to saline without affecting other outcomes.
This document discusses renal replacement therapy for acute kidney injury (AKI) in intensive care unit patients. It defines AKI and its prevalence in ICU patients. It describes the various modes of renal replacement therapy including intermittent hemodialysis, continuous renal replacement therapy and peritoneal dialysis. It discusses indications for starting renal replacement therapy and debates the optimal timing, modality and dosing of therapy. While several studies have examined these issues, the document concludes that the choice of renal replacement therapy should be individualized for each critically ill patient based on their condition and available resources.
This document discusses fluid therapy and management. It begins by questioning common practices around fluid administration and their physiological effects. It notes that much of the fluid given intravenously leaks out of blood vessels rapidly. The concept of "third spacing" of fluid is questioned as evidence supporting it is flawed. Recent evidence points to fluid loading damaging the endothelial glycocalyx layer. Guidelines recommend restrictive fluid therapy with goal-directed monitoring to avoid complications of excess fluid like organ edema. Fluid needs vary by patient and surgery type, and fluid should be administered to address specific deficits or goals rather than by routine formulas.
Fluid management is essential for peri-operative patient care and impacts outcomes. Three key considerations for fluid prescription include the purpose of the fluid, the patient's weight and comorbidities, and laboratory values. Crystalloids are commonly used for volume resuscitation while colloids provide more sustained plasma expansion but risk allergic reactions. Proper fluid status assessment and strict input-output monitoring are important to avoid overhydration or dehydration.
continous versus intermittent RRT in the ICU Salwa Ibrahim
This document discusses different modalities of continuous renal replacement therapy (CRRT) for critically ill patients with acute kidney injury, including CVVH, CVVHDF and CVVHD. It summarizes evidence from randomized controlled trials and systematic reviews showing no significant differences in mortality or renal recovery rates between CRRT and intermittent hemodialysis. Slow low efficiency daily dialysis (SLED) is presented as a hybrid therapy that combines benefits of CRRT and economics of intermittent hemodialysis. A cost analysis shows CRRT is more expensive than SLED due to additional consumables and fluids required. The conclusion is that while CRRT may provide higher blood pressure, there is no evidence it improves survival over intermittent
This document provides an overview of renal replacement therapies used in critical care settings. It discusses some of the key questions around when and how to use these therapies for acute kidney injury (AKI) patients. While there is no definitive evidence that answers all the questions, the literature suggests starting renal replacement therapy early according to RIFLE criteria and aiming for a minimum dose of 35 ml/kg/hr. Choice of therapy mode (intermittent vs continuous) may not be as important as ensuring adequate dosing. Further research is still needed to fully understand how to optimize outcomes for AKI patients requiring renal replacement therapy.
This document provides an overview of fluid and electrolyte management in surgical patients. It discusses the normal composition and homeostasis of body fluids, as well as different types of intravenous fluids including crystalloids and colloids. It then covers perioperative fluid therapy and management of common electrolyte imbalances like sodium and potassium. The key goals are to maintain adequate intravascular volume and tissue perfusion while avoiding complications from fluid overload or electrolyte abnormalities.
1. Perioperative fluid management aims to maintain adequate blood volume and tissue oxygenation to improve outcomes. Strict fluid balance is important to avoid complications.
2. Goal-directed hemodynamic therapy using parameters like stroke volume variation can optimize tissue oxygen delivery and reduce postoperative infections and complications.
3. In trauma patients requiring massive transfusion, plasma should be administered in a ratio of 1:1 to 1:2 with packed red blood cells to replace clotting factors and improve outcomes. Point-of-care coagulation monitoring helps guide administration.
AKI in the ICU
Principles of RRT
Modes of RRT
Indications for RRT
Optimal timing: When to start
Optimal modality: What Modality and Where ??
Optimal dosing- How Much?
Summary and Conclusions
This document discusses intravenous (IV) fluid choice from an intensive care perspective. It begins by introducing IV fluids as a cornerstone treatment in emergency and intensive care medicine and discusses the debate around the relative safety of different IV fluid formulations. It summarizes the findings of several large randomized controlled trials that compared colloids to crystalloids and found increased risks of harm with some colloids. The document analyzes the safety of different IV fluid options like albumin, hydroxyethyl starches, and crystalloids based on evidence from major trials. It concludes that normal saline is generally the default fluid but that more physiological crystalloids may be preferable in some situations like burns or metabolic acidosis.
- Renal replacement therapies are important in critical care for managing complications of renal failure such as fluid, electrolyte and acid-base imbalances. There are many questions around optimal therapy including timing, dose and modality.
- Acute kidney injury is common in the ICU and associated with worse outcomes. Continuous renal replacement therapies may provide more stable volume and chemistry control compared to intermittent therapies.
- High volume hemofiltration shows promise for removing inflammatory mediators in sepsis but optimal dose is still unclear. Renal replacement therapies have an important role beyond renal support as blood purification techniques.
This document summarizes key aspects of fluid management in peritoneal dialysis (PD) patients. It discusses optimizing PD prescriptions to balance adequate solute clearance while avoiding excess dialysis fluid exposure. Factors like residual renal function, membrane characteristics, fill volume and dwell time are considered. Monitoring adequacy includes measuring clearances and adjusting therapy if targets are not met. Guidelines recommend strategies to preserve renal function like ACEi/ARB use and avoiding dehydration.
Similar to RINGERS LACTATE VS NORMAL SALINE.pptx (20)
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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1. INTRAVENOUS FLUID THERAPY:
THE CASE OF NORMAL SALINE
VS RINGERS LACTATE
DR ANTHONY KWAW, RESIDENT PHARMACIST
ACCIDENT AND EMERGENCY
TAMALE TEACHING HOSPITAL
TAMALE, GHANA
Email: kwawanthony7@gmail.com
1
2. OUTLINE
• Introduction
• Comparative studies
• Myths on Ringers lactate use
• Specific indications for Ringers lactate
• Considerations for alternative IVF to Ringers lactate
• Practice Points
• Conclusion
• References
2
3. Patient Case Scenario
A 70-year-old-female is brought to the ED for altered mental status. The
patient has had decreased PO intake over the last 3-4 days and fever and
confusion that worsened in the last 24 hours. Her past medical history is
significant for hypertension and coronary artery disease.
Vitals are notable for a blood pressure of 82/44mmHg, HR of 118bpm,
temperature of 39.10C, RR of 14cpm, and SPO2 96% on RA. The patient
appears confused and dehydrated. Evaluation reveals a WBC of
24,000mm3, lactate of 6.0mEq/L, K of 5.8mEq/L, and UTI on urinalysis.
You have identified that the patient is in septic shock and requires fluid
resuscitation.
What fluid will you use to resuscitate your patient? What evidence will
support that decision? Does the patients’ elevated lactic acid and potassium
play a role in your choice of fluid? 3
4. Intravenous Fluids
A 70kg adult requires 2-2.5L of fluids over 24 hours
Losses are through urine (1.5L), stool (0.2L), and insensible losses
(0.8L)
This requirement is normally met through food (1000mL) and drink
(1500mL).
IVF are given if sufficient fluids cannot be given orally.
Fluids are a standard treatment for various disease processes that
present to the ED. 4
5. Intravenous Fluids
Thought to increase intravascular and intracellular volume, fluids are
critical in treatment of multiple disease processes that cause
dehydration and loss of circulating fluid, leading to hypoperfusion and
hypotension
Historically, NS has been the fluid of choice for resuscitation
Recent debate about preferred fluids based on composition in the
treatment of various illnesses
5
8. Normal distribution of water (Adults)
8
• For a 70kg man, total bodily fluid is ~42L
(60% body weight); 36L in a 60kg adult
• ⅔ is intracellular (25-30L) and
• ⅓ is extracellular (13-16L).
• Of the extracellular compartment, ⅓ is
intravascular, i.e. blood (5L)
• Lymph and transcellular fluid are 1.5L each
9. Normal distribution of water (Infants)
9
• Water constitutes about 75-80% of the body weight.
• Solids constitute about 20 to 25% of the body weight.
• The total volume of water in an infant is about 3L
• The water in the intracellular compartment is ≈
30% of the body weight.
• Water in the extracellular compartment constitutes
45% of the body weight.
• Plasma constitutes about 4% of the body weight of
an infant
10. Types of Intravenous Fluids
• Dextrose 5%:
• Isotonic
• Small amount of glucose ~50g/L
• small energy (~10% daily energy per liter)
• liver rapidly metabolizes all the glucose leaving only water, which rapidly
equilibrates throughout all fluid compartments.
• Not suitable for fluid resuscitation (only 1/9 will remain in the intravascular
space), but suitable for maintaining hydration.
• Excess 5% glucose IV may lead to water overload and hyponatremia
• Dextrose 10% and 50%
• Hypertonic
• Used to correct hypoglycemia 10
11. Types of Intravenous Fluids
• Dextrose in Sodium chloride
• Required for fluid maintenance
• 1/5 Dextrose in 0.18% Sodium chloride used in pediatric setting
• 5 % Dextrose in 0.9% Sodium chloride used in adult patients
• Colloids (e.g. Gelofusine)
• Have a high osmotic content similar to that of plasma and therefore remain in
the intravascular space for longer than other fluids, making them appropriate
for fluid resuscitation, but not for general hydration.
• Colloids are expensive, and may cause anaphylactic reactions.
• In reality, effective fluid resuscitation will use a combination of colloid and
0.9% saline
11
12. Types of Intravenous Fluids
Sodium chloride 0.9%
• About the same Na+ content as plasma
(150mmol/L) and is isotonic with plasma.
• Equilibrate rapidly throughout the
extracellular compartment only, but takes
longer to reach the intracellular
compartment than 5% glucose.
• Appropriate for fluid resuscitation, as it
remains predominantly in the extracellular
space
• Also for maintaining hydration
Ringers lactate
• Considered more physiological due to
the similarity in its composition
compared to human plasma
• Less risk of causing acidosis compared
to NS
12
13. IVF COMPOSITION
Contents Human plasma NS RL Plasma-lyte A
Sodium (mEq/L) 135-145 150 130 140
Potassium (mEq/L) 4.5-5.0 0 4 5
Chloride (mEq/L) 94-111 154 109 98
Calcium (mEq/L) 2.2-2,6 0 2.7 0
Magnesium (mEq/L) 0.8-1.0 0 0 3
Bicarbonate (mEq/L) 23-27 0 0 0
Lactate (mEq/L) 1-2 0 28 0
Acetate (mEq/L) 0 0 0 27
Gluconate (mEq/L) 0 0 0 23
pH 7.4 5.5 6.5 7.4
13
• NS has relatively more chloride than human plasma; risk of hyperchloremic metabolic acidosis
• This may delay recovery in some disease process and may contribute to worsening renal function during treatment
• Elevated chloride causes renal vasoconstriction and may decrease renal perfusion via this mechanism
15. Saline Against Lactated ringers or Plasma-Lyte in
the Emergency Department (SALT-ED) Trial
(Wesley et al., 2018)
• An RCT conducted in 2016 (over 16 months) to compare NS and
balanced crystalloids in non-critically ill patients (n= 13,347)
• A single-center, pragmatic, multiple-crossover trial
• Trial evaluated hospital-free days (days alive after discharge before
day 28) as well as major adverse kidney events within 30 days
• composite of death from any cause
• new renal replacement therapy
• persistent renal dysfunction with creatinine >200% from baseline
15
16. SALT-ED TRIAL- Outcome
16
• Primary outcome of hospital-free days did not have a significant difference
between NS and balanced crystalloid groups
• Significantly lower rate of adverse major kidney events in 30 days between
balanced crystalloid and NS groups (4.7% vs. 5.6%)
• Patients in the balanced crystalloid arm showed lower chloride and higher
bicarbonate concentrations persisting for several days into hospitalization.
• Patients with underlying renal dysfunction or hypochloremia at presentation
appeared to have the largest benefit from the balanced crystalloid therapy by
having reduced incidents of major adverse kidney events in 30 days
17. Isotonic Solutions and Major Adverse Renal
Events Trial (SMART) (Semler et al., 2018)
• An RCT conducted in 2016 (over 16 months) to compare NS and balanced
crystalloids in critically ill patients (n= 15,802)
• A pragmatic, cluster-randomized, multiple-crossover trial
• The primary outcome was a major adverse kidney event within 30 days
• composite of death from any cause
• new renal replacement therapy
• persistent renal dysfunction with creatinine >200% from baseline
17
18. SMART TRIAL- Outcome
• Significant decrease in major adverse kidney events within 30 days for
balanced crystalloids vs NS (14.3%% vs 15.4%, p=0.04)
• Insignificant decrease in in-hospital mortality at 30 days for the
balanced crystalloid vs. NS group (10.3% vs 11.1%, p=0.06).
• Similarly, the balanced crystalloid group showed lower incidence of
hyperchloremia defined as Cl > 110 mmol/L (24.5% VS 35.6%) and
lower incidence of plasma bicarbonate concentration < 20 mmol/L
(35.2% vs. 42.1%) when compared to NS.
18
19. SMART TRIAL- Outcome
• The incidence of new renal-replacement therapy for the balanced
crystalloid vs. NS group was 2.5% and 2.9%, respectively (P=0.08)
• The incidence of persistent renal dysfunction for the balanced
crystalloid vs. NS group was 6.4% and 6.6%, respectively (P=0.60).
19
20. SMART TRIAL- Outcome
• Importantly, patients with a diagnosis of sepsis had lower incidence of 30-
day mortality in the balanced crystalloid vs. NS groups (25.2% vs 29.4%,
p=0.02).
• This is also important because fluids are a key treatment in sepsis and
volume of fluid resuscitation is often higher..
• Based on these results, 1 in every 94 patients admitted to the ICU and
treated with balanced crystalloid instead of NS may prevent the need for
new renal replacement therapy, persistent renal dysfunction, or death when
compared to NS
20
21. SALT-ED + SMART
21
• These two RCTs are groundbreaking and practice changing, leading
many emergency departments and intensive care units to transition to
more regularly using balanced crystalloids over NS.
• While conclusions of the trials often point to RL being superior to NS,
it can also be reassuring that NS was given to so many patients
without substantial harm.
22. What if……..?
22
• The volume of IVF administered in this studies may be more
important than the specific type of fluid
• i.e. worse outcomes with excess IVF
23. Balanced Solution versus Saline in Intensive
Care Study (BaSICS Trial) (Zampieri et al.,
2021)
23
• A robust RCT that compares plasma-lyte with normal saline for fluid
resuscitation in the ICU and two rates of fluid administration, 999
ml/hr and 333 ml/hr (n=11,000)
• A multicenter, double blind RCT from 75 ICUs across Brazil
• Primary outcome was a 90-day mortality rate between fluid type and
rate of IVF infusion
24. BaSICS Trial-Outcome
24
• 90-day mortality rate was;
• 26.4% in the plasma-lyte group and 27.2% in the NS group (aHR 0.97, CI
0.90-1.05, P=0.47)
• 26.6% in the slower infusion rate vs 27.0% in the faster infusion rate group
(aHR, 1.03; 95% CI, 0.96-1.11; P=0.46).
• A secondary outcome from the BaSICS trial showed no significant
difference in need for renal replacement therapy or doubled creatinine
in balanced crystalloid group (27.8%) versus NS group (28.9%) (95%
CI, 0.86-1.04, p=0.37)
25. Crystalloid Liberal or Vasopressors Early
Resuscitation in Sepsis Trial (CLOVERS TRIAL)
25
• The idea of “you have to swell to get well” is no longer the standard of
care, and permissive hypotension is preferred in several disease states.
• CLOVERS seeks to compare early transition from fluids to vasopressors
in patients with septic shock and also answer important question about
fluid volume and rate or volume given to patients during resuscitation
• A multicenter, randomized, un-blinded, two-arm clinical trial to
determine the impact of a restrictive fluids (“Medicine to Raise Blood
Pressure First”) strategy as compared with a liberal fluids (“Fluids
First”) strategy on 90-day in-hospital mortality (n=2,320)
26. Update on CLOVERS Trial
• Phase 3 stopped in February, 2022
• No significant difference observed between the two arms in the first 24 hours
of treatment (n=1,566)
• No significant difference in 90-day mortality rates nor safety concerns
• They will continue patient follow-up according to the study protocol
for those already enrolled in the trial
• Conducted by the PETAL Network and sponsored by NHLBI
26
27. RL or NS?
27
• BaSICS trial makes it clear that there is not one fluid that is ideal, and
certain populations and diseases will benefit from selected fluid choice
• SALT-ED and SMART trials showed that both non-critically ill and
critically ill patients who received balanced crystalloids were less
likely to have renal injury leading to need for renal replacement
therapy or to have persistent renal dysfunction, but an additional large
ICU based RCT (BaSICS Trial) did not show statistical difference in
balanced crystalloid versus NS.
• Fluid therapy should be targeted to specific patient populations and
presenting disease.
28. Myths surrounding Ringers lactate!!!
• Despite these studies, there are still several concerns regarding the use
of RL in the ED
28
29. 1. Hyperkalemia
• Myth – “Ringers lactate should not be used in hyperkalemia because it
contains potassium and may make the problem worse.”
• Hyperkalemia is the electrolyte abnormality most likely to quickly kill a
patient
• Causes;
• Drugs (Co-trimixazole, ACEIs, ARBs, Potassium-sparing diuretics etc.)
• Rhabdomyolysis
• Cell death
• Though Ringers lactate contain a higher concentration of potassium (4mEq/L)
when compared to NS (0 mEq/L), its potassium composition is physiologically
closest to human serum (4.5-5.0mEq/L) and is typically slightly lower 29
30. Hyperkalemia
• There is negligible effect on overall serum potassium level as a result of RL
infusion since potassium’s volume of distribution is greater in extracellular fluid
causing little to no change on the overall serum potassium level.
• It would take a significant amount of fluid to have any effect on raising overall
serum potassium level since the potassium equilibrates between intracellular and
extracellular fluid spaces.
• Hyperchloremic metabolic acidosis which can result from NS infusion will
increase cellular shifting and worsen extracellular potassium levels when
compared to RL which has no effect on the K+/H+ gradient.
• Alkalinization that occurs as a result of RL infusion due to the 28 mEq/L of
lacatate may even further drive potassium into the cell, lowering the overall
serum potassium level. 30
31. Hyperkalemia
• One subgroup analysis from the SMART trial evaluated critically ill adults
with hyperkalemia who received balanced crystalloids RL or plasma-lyte
vs. NS.
• Overall, 8 (8.5%) of the patients in the balanced crystalloid group vs. 13
(14.0%) patients in the NS group developed severe hyperkalemia (p=0.24).
• While this is not statistically significant, it does show that the higher level
of potassium that is administered from RL or plasma-lyte (4-5) vs. NS (0) is
closer to physiologic plasma and does not lead to worsening hyperkalemia.
31
32. Hyperkalemia
• Pearl:
RL is a safe fluid to use in resuscitation of patients with elevated
potassium levels. The potassium/hydrogen shifts that occur as result
of the acidic environment from normal saline infusion may worsen
serum potassium levels.
32
33. 2. Lactic acidosis
• Myth – “Ringers lactate causes lactic acidosis, and therefore should be avoided.”
• Lactic acidosis is a result of failed oxidative metabolism, leading to an anion-gap
metabolic acidosis.
• This can be secondary to decreased metabolism of naturally generated lactate in the
body (such as in liver disease) or increased production of lactate when there is
decreased oxygen available for aerobic metabolism.
• Causes;
• sepsis,
• trauma
• dehydration.
• iatrogenic causes of type B lactic acidosis secondary to beta agonist administration, such as
epinephrine or albuterol (less common)
33
34. Lactic acidosis
34
• The lactate in RL is in the form of sodium lactate which our bodies
metabolize to products that prevent cellular death.
• It is not the same lactate that is generated during anaerobic metabolism,
which causes metabolic acidosis (Robergs et al., 2017)
• One double-blind RCT evaluated the change in lactate between RL and NS
groups while also looking at the overall change in pH, bicarbonate, sodium,
and chloride levels.
• This study found that after an infusion of 30mL/kg IV RL, lactate increased
by 0.93 mmol/L compared to 0.37 mmol/L in the NS group (p=0.2), but the
NS group saw a larger decline in overall pH (0.06 vs. 0.03) and bicarbonate
level (2.35 vs. 0.36) (Zitek et al., 2018)
35. Lactic acidosis
35
• In an additional RCT published by Didwania et al. (1997), 24 healthy
adults received 1L infusions of RL, NS, dextrose, or D5W and showed
no difference in lactate levels post-infusion
• It is theorized that the lactate infused in the RL group may be
metabolized under ischemic conditions and decrease overall cell death
and is less likely to worsen an acidosis when compared to the
hyperchloremic acidosis that results from NS.
• Pearl:
Though RL contains sodium lactate, this is generally metabolized by the
body and does not contribute to worsening lactic acidosis. In fact, the
acidosis associated with NS likely has more clinically harmful effects.
36. 3. Medication Reactions
36
• Some Truth – “Because ringers lactate can have calcium precipitation with so
many medications, it is easier and safer to use normal saline.”
• It is postulated that the sodium concentration within ceftriaxone contributes to
the formation of calcium precipitates and therefore the mixture of these
solutions in the same line should be avoided.
• An additional study evaluated compatibility of RL with 94 medications by in
vitro visual observation, particle counting testing, and light obscuration particle
count testing.
• Eight drugs were considered incompatible with RL including ciprofloxacin,
cyclosporine, diazepam, ketamine, lorazepam, nitroglycerin, phenytoin, and
propofol and are recommended against administering through the same IV line
as RL (Vallee et al., 2021)
37. Medication Reactions
37
• Two separate studies were performed to evaluate the incidence of clot
formation when RL was transfused with packed RBCs and Whole Blood.
• In both studies, there was no statistically significant difference in clot
formation when NS or RL was infused or used as a diluent in emergent
transfusions.
• There is however, a theoretical risk of coagulation when RL is administered
together with preserved blood (with citrate anticoagulant) via the same
infusion set (Singh et al, 2021; Lorenzo et al., 1998; Cull et al., 1991)
38. Medication Reactions
38
• Pearl:
Though theoretical risk of clotting exists, RL can be administered
simultaneously in patients >28 days with ceftriaxone, blood products
and other calcium-containing medications. If possible, a separate line
should be used to avoid potential precipitation.
40. 1. Diabetic Ketoacidosis (DKA)
• In DKA, the body responds to low insulin levels by burning fatty acids
and producing ketone bodies, leading to an anion-gap metabolic
acidosis.
• Often overall body potassium is low; however, it may appear to be
falsely elevated due to hydrogen ions shifting intracellularly and
potassium moving extracellularly.
• Fluids, in addition to insulin and potassium, are the main treatment for
this disease process
40
41. Diabetic Ketoacidosis (DKA)
• One subgroup analysis from the SALT-ED and SMART trial compared
patients with a clinical diagnosis of DKA to look at;
• time to resolution (glucose <200 mg/dL)
• 2 of the following: bicarb > 15, venous pH >7.3, anion gap ≤ 12)
• time to discontinuation of insulin infusion.
• Given the sheer volume of fluid required to treat this disease process,
(on average, 4.5 liters) differences in fluid composition can be a key
factor in recovery.
41
42. Diabetic Ketoacidosis (DKA)
42
Outcome
• significant decrease in both time to resolution of DKA (13 hours vs 16.9 hours)
in the balanced crystalloid group as well as time to insulin discontinuation (9.8
hours vs 13.4 hours).
• This equates to an absolute reduction of 4 hours and relative reduction of 20-
30% in time to DKA resolution and discontinuation of insulin infusion,
possibly decreasing overall hospital stay and associated morbidity.
• This is hypothesized to be due to the concentrations of sodium lactate in RL
and acetate in plasma-lyte which metabolize into bicarbonate helping to close
the anion gap metabolic acidosis.
43. Diabetic Ketoacidosis (DKA)
• Additionally, fewer patients in the balanced crystalloid group
exhibited hypokalemia (K+ < 3mmol/L) compared with the NS group.
• However, this study was in contrast to prior work on the subject which
failed to show any significant difference (Self et al., 2017; Mahler et
al., 2011; Van Zyl et al., 2012; Jayashree et al., 2019; Yung et al.,
2017)
43
44. 2. Dehydration
• In patients with dehydration (defined as dry mucous membranes, SBP <90
mmHg, HR >100 bpm or PO intolerance), a RCT comparing NS and
balanced crystalloids showed significantly lower pH levels in patients who
received NS (7.40 7.37 7.36) as well as a drop in bicarbonate levels (23.1,
22.2, 21.5) compared to an increase in the plasma-lyte group (7.40 7.42
7.45) and (23.4, 23.9, 24.4) (Hasman et al., 2012)
• A similar study conducted in pediatric patients with acute diarrhea and
severe dehydration showed no significant difference in pH between NS and
RL, but the RL group required less fluids (310 vs 530mL) and had a shorter
median hospital stay (38 vs 51 days) (Mahajan et al., 2012)
44
45. 3. Pancreatitis
• One RCT compared RL with NS in patients with acute pancreatitis and found a
significant reduction in SIRS after 24 hours in the RL group (84% vs 0%, p=0.035).
• There was also a reduction in CRP in the RL group (51.5 vs 104, p=0.02), a marker of
systemic inflammation (Wu et al., 2011)
• An additional study by Lee et al. (2021) showed that there was a significantly shorter
hospital length of stay and fewer ICU admissions in patients diagnosed with acute
pancreatitis who were treated with aggressive fluid resuscitation via RL compared to NS
• Though the exact mechanism is unknown, there are animal studies showing decrease in
enzymes involved in pancreatitis such as zymogen (Khatua et al., 2020)
Pearl:
Several studies shows balanced crystalloids are associated with improved outcomes in
patients with DKA, dehydration, and pancreatitis.
45
48. 1. Traumatic brain injury
• It is theorized that due to hyperosmolarity of the solution and ability to decrease
cerebral edema, NS is the preferred resuscitation fluid in patients with Traumatic
Brain Injuries (TBI) when compared with RL
• Additionally, RL is thought to increase neutrophil and inflammatory responses.
• One study comparing outcomes of patients with TBI who were treated with RL vs NS
prior to hospital arrival found RL was associated with higher 30-day mortality than
NS (HR = 1.78, CI 1.04 – 3.04, p=0.03) (Rowell et al., 2016)
• Subgroup analysis on this topic with the best RCT to date, BaSICS Trial, showed that
a balanced crystalloid (plasma-lyte) had higher 90-day mortality rate (31.3%) versus
NS (21.1%) (HR 1.48, 95% CI 1.03-2.12, p=0.02) (Zampieri et al., 2021)
48
49. 2. Hyponatremia
• RL contains 130 mEq/L Na compared to 135-145mEq/L Na in plasma. Because of
this, there is concern that resuscitation with RL may worsen or lead to
hyponatremia.
• There is limited data around RL causing hyponatremia or the use of RL in treating
acute hypovolemic hyponatremia in the Emergency Department setting.
• One study evaluated post-operative hyponatremia and cited quantity of fluid
resuscitation as the cause of hyponatremia versus use of RL itself.
• The theory is that increased extracellular volume leads to ADH release and worsens
hyponatremia. (Steele et al., 1997)
49
50. 3. Burns
50
• In acute burns, there is concern for both dehydration and electrolyte
imbalances such as hyponatremia and hypoglycemia secondary to
evaporative losses and changes in cellular permeability.
• One RCT evaluated the use of RL alone in burn resuscitation when
compared to use of RL and Dextrose in NS in an attempt to correct
electrolyte abnormalities.
• This study showed that due to low sodium (130mEq/L) and potassium
(4mEq/L) levels in RL when compared to human plasma, dextrose
containing NS should be used as an adjunct to assist in replenishing
electrolytes.
51. 3. Burns
• Burn patients treated with RL and DNS had statistically significant
less evidence of hyponatremia and hypoglycemia (Bedi et al., 2019)
Pearl:
In patients presenting with hyponatremia and acute burns, RL is not
necessarily the sole fluid choice for resuscitation, and NS is preferred
in patients with concern for TBI.
51
52. Practice Points
• Ringers lactate composition is more similar to human plasma than
Normal saline
• Ringers lactate is preferred to Normal saline in select ED presentations,
such as DKA, dehydration and pancreatitis
• Ringers lactate will not worsen hyperkalemia and the acidosis but
Normal saline may in fact be more detrimental
52
53. Practice Points
• Ringers lactate does contain sodium lactate but will not contribute to
clinically significant worsening lactic acidosis
• Normal saline is preferred in patients with TBI.
• Consider Normal saline when mixed with certain medications such as
ceftriaxone or blood transfusions to avoid precipitation when only a
single IV access site it available
53
54. Patient Case Scenario
• The 70-year-old female is febrile with signs of dehydration and hypotension
in the setting of sepsis due to a urinary tract infection.
• She also has lactic acidosis and hyperkalemia on her initial workup.
• Based on the data above, RL is a safe and appropriate approach to fluid
resuscitation in combination with antibiotics.
• Broad spectrum antibiotics should be started and the patient admitted to the
medical ICU for further workup and care.
54
55. CONCLUSION
• No single IVF is superior to the other and the choice should be based
on the clinical condition
• Use of Ringers lactate in most cases has better outcomes compared to
the use of NS
• RL should be the first line IVF for resuscitation in some selected
indications
55
56. REFERENCES
Wilkinson, I.B. et al. (2017). Oxford Handbook of Clinical Medicine. 10th
Edition. Oxford University Press. Page: 666-667
Self, W.H., et al. (2020). Pragmatic Critical Care Research Group. Clinical
Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis:
A Subgroup Analysis of Cluster Randomized Clinical Trials. JAMA Netw Open.
2020 Nov 2;3(11):e2024596
Self, W.H., et al. (2018). SALT-ED Investigators. Balanced Crystalloids versus
Saline in Non-critically Ill Adults. N Engl J Med.1;378(9):819-828.
Self, W.H., et al. (2017). Saline versus balanced crystalloids for intravenous
fluid therapy in the emergency department: study protocol for a cluster-
randomized, multiple-crossover trial. Trials. 2017;18(1):178. 56
57. REFERENCES
Semler, M.W., et al. (2018). SMART Investigators and the Pragmatic Critical Care
Research Group. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J
Med.1;378(9):829-839.
Zampieri, F.G., et al. (2021). Effect of Intravenous Fluid Treatment With a Balanced
Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS
Randomized Clinical Trial. JAMA. Published online August 10, 2021
Zampieri, F.G., et al. (2021). Effect of Slower vs Faster Intravenous Fluid Bolus
Rates on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical
Trial. JAMA. Published online August 10, 2021
Frazee, E., and Kashani, K. (2016). Fluid Management for Critically Ill Patients: A
Review of the Current State of Fluid Therapy in the Intensive Care Unit. Kidney Dis
2016;2:64-71. 57
58. REFERENCES
National Library of Medicine (U.S). (2018, February – present). Crystalloid Liberal
or Vasopressors Early Resuscitation in Sepsis (CLOVERS). Identifier NCT03434028.
https://clinicaltrials.gov/ct2/show/NCT03434028
Simon LV, Hashmi MF, Farrell MW. Hyperkalemia. [Updated 2021 Feb 11]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-
Farkas, J. Myth-busting. Lactated ringers is safe in hyperkalemia, and superior to
normal saline. Online Publication. www.EMcrit.org
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