Fluid selection & pH-guided fluid resuscitation (2024)

Fluid selection & pH-guided fluid resuscitation (1)

CONTENTS

  • Preamble: Why should we care?
  • Albumin
  • Balanced crystalloid vs. normal saline
    • Choice of balanced crystalloid
  • pH-guided resuscitation
  • Therapeutic alkalinization to augment permissive hypercapnia
  • Fluid shortage
    • General approaches to conserve IV fluid
    • Formulation of enteral resuscitation fluid
  • Podcast
  • Pitfalls

preamble: why fluid selection matters

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Fluid choice probably doesn't make much difference for most patients. However, fluid therapy is a widespread intervention. When leveraged over the high number of patients receiving fluid, even slight differences in efficacy can be significant (e.g., NNT of 100). Finally, for occasional patients with substantial pre-existing hyperkalemia or metabolic acidosis, fluid choice may be crucial.

albumin

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summary

  • Currently, albumin seems to be indicated primarily to support renal function among patients with cirrhosis, specifically:
    • [1] Management of SBP (spontaneous bacterial peritonitis).
    • [2] Management of HRS (hepatorenal syndrome).
    • [3] Prophylaxis against hepatorenal syndrome following large-volume paracentesis.
  • Crystalloid is generally preferred for other applications.

2024 guideline on albumin use from the International Collaboration for Transfusion Medicine

  • The following recommendations are made:
    • Albumin isn't generally recommended for first-line volume replacement or to increase serum albumin levels.
    • In critically ill adults, IV albumin plus diuretics aren't suggested to remove extravascular fluid.
    • In patients undergoing dialysis, albumin isn't suggested for the prevention or treatment of intradialytic hypotension or for improving ultrafiltration.
    • In adults undergoing cardiovascular surgery, albumin isn't suggested for priming the cardiovascular bypass circuit or volume replacement.
    • In patients with cirrhosis and ascites undergoing large-volume paracentesis (>5 liters), albumin is suggested to prevent paracentesis-induced circulatory dysfunction.
    • In patients with cirrhosis and spontaneous bacterial peritonitis, intravenous albumin is suggested to reduce mortality.
    • In patients with cirrhosis and intraperitoneal infections, intravenous albumin is not suggested to reduce mortality or kidney failure.
    • In hospitalized patients with decompensated cirrhosis and hypoalbuminemia (<3 g/dL), repeated albumin to increase albumin levels to >3 mg/dL isn't suggested to reduce infection, kidney dysfunction, or death.
    • In outpatients with cirrhosis and uncomplicated ascites, despite diuretic therapy, intravenous albumin is not routinely suggested to reduce complications associated with cirrhosis.
  • These recommendations are sensible and evidence-based. (38447639)

balanced crystalloid vs normal saline

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general rationale for transitioning from normal saline to balanced crystalloids

  • [1] There was never any physiologic rationale to use normal saline in the first place. Most reasons offered to support the use of saline aren't based on physiology or evidence (e.g., “it's cheap” or “it's what we're used to using”).
  • [2] Normal saline exacerbates acidosis. This may be problematic – especially in patients who are severely acidotic to begin with (which isn't uncommon among critically ill patients).
  • [3] Normal saline has been shown to exacerbate hyperkalemia (by causing acidosis, which shifts potassium out of cells). (15845718, 18569935, 22237237, 29121282).
  • [4] In animal models, normal saline causes significant harm compared to balanced crystalloid (e.g., greater acidosis, impaired cardiac function, coagulopathy, impaired renal function, and mortality). (14718447, 27655180) In humans, two RCTs have shown that saline may cause hemodynamic instability, compared to balanced crystalloids. (25185593, 29406176)
  • [5] Hyperchloremia caused by normal saline may cause renal vasoconstriction, increasing the risk of kidney injury. (29485926)
  • [6] Meta-analysis of 34,685 patients involved in RCTs of balanced crystalloid versus normal saline found a trend towards 0.5% lower mortality among patients treated with balanced crystalloid. Although this wasn't statistically significant, using Bayesian statistics, there was a reasonably high likelihood that balanced crystalloid improved mortality (posterior probability 89.5%). (38043564)

arguments for using saline & why they lack merit

  • “Normal saline is cheaper.”
    • Lactated Ringers is only ~25 cents more expensive per liter, and the cost difference of Plasmalyte/Normosol isn't much greater. These differences aren't relevant in the context of a patient's hospital bill, which will range in the thousands of dollars. Additionally,using a balanced fluid may avoid the need for IV bicarbonate and/or dialysis –savinga considerable amount of money.
  • “I will give two liters of saline and switch to a balanced fluid.”
    • First, nobody does that. Human beings aren't that well organized. If physicians and nurses in your unit are used to giving saline and a patient crashes, they'll give saline. They won't check first to see how much saline the patient received.
    • Second, the SALT-ED trial suggested that clinical benefits from balanced crystalloids may occur even if only small volumes are used.
  • “Lactated Ringers isn't safe in hyperkalemia.”
    • Lactated Ringers is fine in hyperkalemia. In fact, it is actually normal saline that is contraindicated in hyperkalemia (more on this here).
  • “Lactated Ringers will elevate the lactate level.”
    • A 30 cc/kg bolus of Lactated Ringers might possibly raise the lactate level by ~0.5 mM.(30037514) Changes in lactate are minimal and will dissipate rapidly because the liver is exceptionally adept at metabolizing lactate. If you're making clinical decisions based on tiny deviations in lactate level, then you're using the lactate lab value wrong.
  • “Lactated Ringers isn't compatible with some drugs (e.g. ceftriaxone).”
    • This shouldn't be a problem if the patient has adequate IV access. Furthermore, Plasmalyte doesn't contain calcium, so it's compatible with a wider variety of drugs.
  • “Lactated Ringers isn't compatible with blood.”
    • This seems to be a myth. Lactated Ringers contains 1.5 mM of calcium. If this concentration of calcium caused blood to clot, then mild hypercalcemia would lead to lethal clotting problems (it doesn't). Several studies have found that Lactated Ringers may be compatible with blood transfusion.(9568658, 19340493, 1866680)

when to use normal saline

  • [1] Normal saline is preferred for patients with significant metabolic alkalosis (discussed further below).
  • [2] Normal saline may be preferred for neuro-ICU patients, especially patients with traumatic brain injury. Meta-analyses and RCTs comparing normal saline with balanced crystalloid have found a worrisome signal of potential harm when balanced crystalloid was used in patients with traumatic brain injury. (38043564)

contraindications to Lactated Ringers

  • Legitimate contraindications:
    • [1] Elevated intracranial pressure (especially due to traumatic brain injury) –Lactated Ringers could theoretically worsen this because it is slightly hypotonic. Evidence supports normal saline as a fluid of choice among patients with traumatic brain injury (as discussed in the section above).
    • [2] Metformin-associated lactic acidosis – In this clinical scenario patients genuinely may have difficulty metabolizing the lactate. Note, however, that lactated ringers contains sodium lactate – so it will increase the lactate level without causing acidosis (more on this here).
    • [3] Severe hypercalcemia – Lactated Ringers has 1.5 mM of calcium, which won't worsen hypercalcemia (if anything it could decrease the calcium level, because this will be a lower calcium concentration than the patient's blood). However, this isn't the optimal fluid here (more on this here).
  • (These are not legitimate contraindications.)
    • Hyperkalemia (more on this here).
    • Cirrhosis or liver injury (unless the patient has frank hepatic failure, it will be able to metabolize lactate).

what is the best balanced crystalloid?

  • Differences between various balanced crystalloids are minor and probably of little clinical significance.
  • LR is usually an excellent choice since it is inexpensive, widely available, and physiologically sound (the choice of lactate as an anion is arguably superior to gluconate/acetate, as discussed below).Outside of a neurological ICU, LR would be an excellent choice for most patients and a safe choice for nearly all patients.
  • Plasmalyte is also an excellent choice, which might be superior to lactated ringers among patients with hypercalcemia.

Fluid selection & pH-guided fluid resuscitation (2)

Fluid selection & pH-guided fluid resuscitation (3)

discussion of various anions in balanced crystalloids

  • Sodium lactate:
    • Historically, lactate administration was feared (due to worsening of “lactic acidosis”). This isn't possible because sodium lactate isn't an acid.
    • Lactate may function as a metabolic fuel for the heart, so if anything, lactate could be a good thing. Hypertonic sodium lactate infusion has been shown to improve cardiac function. (24666826)
    • In vivo, the liver metabolizes lactate very rapidly into bicarbonate (unless the patient has fulminant hepatic failure).
  • Sodium acetate:
    • Sodium acetate is rapidly metabolized into bicarbonate.
    • Acetate lacks lactate's beneficial cardiac effects. Excessive acetate levels may cause vasodilation and hypotension, but this doesn't seem to be clinically relevant (acetate will be rapidly metabolized and only transiently present).
  • Sodium gluconate:
    • Although often believed to be metabolized into bicarbonate, this doesn't seem to be the case – so sodium gluconate does not function as an alkali (unlike sodium acetate and sodium lactate). This means that Plasmalyte has the same exact pH effect as Lactated Ringers.
    • Sodium gluconate appears to be cleared unchanged from the kidneys. It could even function as an osmotic diuretic agent.

pH-guided resuscitation

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general concept

  • Crystalloid resuscitation may be utilized to improve pH status among selected patients.
    • Fluid should be viewed as a drug.
    • Just as we wouldn't give the patient “any antibiotic,,” we shouldn't give “any fluid.” The fluid should be selected to maximize benefit.
  • Fluid resuscitation is a limited opportunity to manipulate pH status.
    • Large volumes of fluid can affect the patient's pH status.
    • After the patient is volume resuscitated, this opportunity will be lost (because large volumes of fluid can no longer be given without causing volume overload).

pH abnormalities treatable with crystalloid

  • (1) Non-anion-gap metabolic acidosis (NAGMA)
    • This represents a bicarbonate deficit (whether bicarbonate has been lost in the stool or urine).
    • Patients with normal kidneys will eventually re-generate bicarbonate, but this takes time. Furthermore, critically ill patients frequently have renal insufficiency or renal tubular acidosis, which prolongs recovery from NAGMA.
    • Exogenous bicarbonate administration is a physiologically logical and well-accepted treatment for NAGMA.
  • (2) Uremic metabolic acidosis
    • Most forms of anion-gap metabolic acidosis (e.g. lactic acidosis or ketoacidosis) don't respond favorably to IV bicarbonate. One exception to this rubric may be uremic metabolic acidosis.
    • Nephrologists have long used exogenous bicarbonate to improve pH and avoid dialysis. This practice was recently validated in the BICAR-ICU trial, wherein bicarbonate administration decreased the requirement for dialysis in uremic patients (more on this here).
  • (3) Acute metabolic alkalosis
    • Most forms of metabolic alkalosis in the ICU are chronic (e.g., chronic compensatory metabolic alkalosis in response to chronic respiratory acidosis). Compensatory alkalosis should be left alone.
    • Acute metabolic alkalosis may occur rarely. It may be caused by the ingestion of large quantities of alkali, large-volume diuresis (contraction alkalosis), or gastric losses (vomiting, continuous NG suction).
    • Normal saline is a rational therapy for acute metabolic alkalosis because it reduces the serum bicarbonate level back to normal.
  • Note that the following abnormalities are not treatable with crystalloid:
    • Chronic metabolic alkalosis which is compensatory for a chronic respiratory acidosis.
    • Anion-gap metabolic acidoses other than uremia (e.g. lactic acidosis or ketoacidosis).

pH-guided resuscitation

Fluid selection & pH-guided fluid resuscitation (4)

  • This is pretty simple—it largely amounts to considering the patient's pH status and whether a choice of IV fluid could improve it.
  • When giving bicarbonate, the bicarbonate deficit may be a useful guide:
    • Bicarbonate deficit (in mEq) can be estimated this calculator from MDCalc.
    • Each liter of isotonic bicarbonate contains 150 mEq of bicarbonate (more on this below).
  • During a bicarbonate shortage, sodium acetate can be used in its place.

pH-guided resuscitation is most important in uremic metabolic acidosis

  • Uremic metabolic acidosis is probably the most common situation where pH-guided resuscitation is beneficial.
  • Isotonic bicarbonate may improve the pH and help avoid dialysis. Alternatively, if the patient is resuscitated to a euvolemic state without isotonic bicarbonate, it will become impossible to provide them with an adequate amount of bicarbonate (these patients are often oliguric, so further fluid could provoke pulmonary edema).
  • These patients are often hyperkalemic, a process that is also improved by isotonic bicarbonate (discussed further in the chapter on hyperkalemia).
  • Overall, there is a subset of patients with acute kidney injury, uremic metabolic acidosis, and hyperkalemia who will respond very favorably to isotonic bicarbonate with the resolution of their electrolytic problems. This may buy them some time for their kidneys to recover, potentially avoiding dialysis.

hypertonic & isotonic bicarbonate

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Fluid selection & pH-guided fluid resuscitation (5)what is isotonic bicarbonate?

  • Isotonic bicarbonate is generally formulated by adding 150 mEq of sodium bicarbonate to a liter of D5W (above).
  • Although fluid outside the body will be hypertonic, glucose doesn't function as an effective osmole (since it readily enters cells). Therefore, in vivo, this solution will behave as an isotonic fluid.
  • D5W is the base solution because most hospitals lack IV sterile water. If your hospitalhas IV sterile water, this would be preferable to D5W to produce a pure isotonic bicarbonate solution.

Fluid selection & pH-guided fluid resuscitation (6)isotonic bicarbonate vs. hypertonic bicarbonate

  • The most commonly used forms of bicarbonate are hypertonic bicarbonate (undiluted ampules) and isotonic bicarbonate (see table above).
  • The amount of hypertonic bicarbonate that can be given is limited by the sodium concentration. Each 50-ml ampule of bicarbonate will increase the sodium concentration by roughly ~1-1.5 mM. Caution needs to be exercised with repeated ampules, as eventually, this will cause hypernatremia.
  • The amount of isotonic bicarbonate that can be given is generally limited by volume overload. Each 150 mEq of bicarbonate comes along with a liter of volume.

dissolved CO2 & how rapidly can isotonic bicarbonate be given?

  • Intravenous bicarbonate contains both bicarbonate and dissolved CO2. For example, the concentration of pCO2 in an ampule of bicarbonate may be ~100 mm.
  • After administration:
    • Dissolved CO2 will transiently increase the patient's pCO2. Over time, this will be breathed off, and the patient will return to their prior pCO2 level. This will happen even if the patient is on mechanical ventilation (administered pCO2 increases the gradient driving CO2 out of the body, increasing CO2 clearance and eventually returning the patient to their baseline pCO2). The only situation where CO2 doesn't return to baseline is if the patient has died (e.g., cardiac arrest, with minimal effective circulation).
    • Bicarbonate persists longer after the pCO2 has been exhaled, explaining the alkalinizing effect of IV bicarbonate.
  • Ampules of sodium bicarbonate should generally not be pushed rapidly. Doing so may cause rapid pH shifts, including elevated pCO2. Thus, if possible, ampules of hypertonic bicarbonate should generally be pushed slowly over ~5-10 minutes.
  • Isotonic bicarbonate can be infused at rates similar to other crystalloids (e.g., 75-1,000 ml/hr). Given the lower concentration of CO2 in isotonic bicarbonate, rapidly loading the patient with CO2 isn't an issue here.

effect of hypertonic bicarbonate versus isotonic bicarbonate on potassium concentration

  • Three factors are in play here:
    • [1] Hypertonicity causes potassium to shift out of cells (a process known as solute drag).
    • [2] Bicarbonate increases the pH, which shifts potassium into cells.
    • [3] The volume load of isotonic bicarbonate may directly dilute potassium, decreasing the potassium concentration.
  • Hypertonic bicarbonate:
    • Factors #1 & #2 cancel each other out.
    • Several RCTs have shown that hypertonic bicarbonate does not affect potassium levels.
  • Isotonic bicarbonate:
    • Factors #2 & #3 both serve to reduce the potassium level.
    • Available data shows that isotonic bicarbonate decreases the potassium level among patients with metabolic acidosis. (1552710, 24132, 1668124)
  • Clinical significance depends on what you're trying to achieve:
    • Hyperkalemia: If you're trying to reduce the potassium level, use isotonic bicarbonate.
    • Hypokalemia: If you're trying to increase the pH without dropping the potassium, then hypertonic bicarbonate could have an advantage.

hypocalcemia

  • Increases in pHtend todecrease the ionized calcium level (essentially, theremoval of protons stuck to albumin renders albumin more negatively charged, leading to an increase in calcium-albumin binding).
  • Increasing the pH to a normal range shouldn't cause hypocalcemia but may exacerbate pre-existing hypocalcemia.

common errors with bicarbonate

  • Don't be afraid to run isotonic bicarbonate at the rate you need. For example, in a severely hypovolemic patient who needs fluid and bicarbonate, you may wish to run the isotonic bicarbonate at 250-1,000 ml/hr (to provide both volume and bicarbonate).
  • Don't slam in an ampule of hypertonic bicarbonate (unless there is a really good reason, such as profound tricyclic intoxication).
  • Don't use hypertonic bicarbonate to treat hyperkalemia (proven not to work).
  • Don't bolus hypertonic bicarbonate for a patient in cardiac arrest (unless you suspect a toxicologic etiology).
  • Don't use bicarbonate to treat lactic acidosis (this doesn't work and gives bicarbonate a bad reputation).

therapeutic alkalization to augment permissive hypercapnia

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basic concept

  • Occasionally, intubated patients are encountered who are extremely difficult to ventilate (typically due to status asthmaticus or severe ARDS).
  • The safest approach for these patients may be to administer exogenous bicarbonate, to increase the bicarbonate level to ~30-35 mEq/L
    • Note that the normal level of bicarbonate in blood is 22-28 mEq/L. Thus, a serum bicarbonate level of 30-35 mEq/L isn't terribly high.
  • This usually shifts patients from mild metabolicacidosis (most patients startwith bicarbonate of ~20 mEq/L) to mild metabolic alkalosis. Higher serum bicarbonate makes it easier to ventilate patients safely (targeting a pH >7.15-7.20). Bicarbonate administration may be safer than increasing the respiratory rate or tidal volume (maneuvers that will increase mechanical force delivered to the lungs and may also increase the risk of pneumothorax).
    • Note that the development of a pneumothorax in a patient with profound ARDS or asthma may be a catastrophic event.
  • Left to their own devices, patients with ARDS or status asthmaticus will often eventually compensate for their respiratory acidosis by mounting a compensatory metabolic alkalosis. Exogenous bicarbonate administration aims to achieve the same thing, merely accelerating this normal adaptation process.
  • There is no high-quality evidence on this topic. The use of exogenous bicarbonate to balance out severe respiratory acidosis is a longstanding practice in critical care (e.g., utilized in the classic ARMA trial on ARDS). (10793162) Unfortunately, there is no precise data to guide the speed and magnitude of alkalization thatmay be optimal.
  • (Further discussion here: 🌊)

Fluid selection & pH-guided fluid resuscitation (7)how to achieve therapeutic alkalization

  • Depending on the patient's weight and baseline bicarbonate, this will generally involveadministering ~150-300 mEq sodium bicarbonate to target a serum bicarbonate level of ~30-35 mEq/L. This should generally be achievedgradually overseveral hours.
  • Hypertonic bicarbonate: Some or all of this exogenous bicarbonate may be administered as hypertonic sodium bicarbonate (8.4%, described above). Hypertonic bicarbonate has the advantage of limiting added volume, but it will eventually cause hypernatremia.
  • Isotonic bicarbonate: This may be useful in patients with hypovolemia or hypernatremia. In a patient with euvolemia and high-normal sodium, isotonic bicarbonate could be combined with diuretics (e.g., furosemide and thiazide diuretics) to achieve alkalinization without causing volume overload.
    • A thiazide diuretic may be helpful here to promote sodium excretion and avoid hypernatremia (more on this here). Furosemide alone tends to cause the excretion of dilute urine, so the combination of furosemide plus isotonic bicarbonate may still tend to increase the patient's sodium level.
  • Bicarbonate administration will cause a transient increase in pCO2 during its administration, which will cause a transient reduction in pH. However, pCO2 will decrease to baseline once bicarbonate administration is completed. Subsequently, the added bicarbonate will increase the pH.
    • If bicarbonate is administered more slowly, transient pCO2 elevations will be smaller. Of course, it will take longer to reach the target pH.
    • This issue of dissolved CO2 is discussed further in the above section in IV bicarbonate.

fluid shortage: approaches to conserve IV fluid

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[1] Give medications & electrolyte repletion orally when possible

  • Electrolytes that may be repleted orally include potassium and phosphate (this is generally cheaper and safer anyway).
  • Medications with high bioavailability should be utilized orally. This includes but isn't limited to:
    • Antibiotics with high bioavailability are listed here: 📖
    • Proton pump inhibitors.
    • Steroid (hydrocortisone, dexamethasone, prednisone).
    • Levetiracetam.
    • Vitamins (folic acid, thiamine).
    • Phenobarbital.

[2] Enteral nutrition (general good practice anyway)

  • Avoid unnecessary NPO orders.
  • Avoid sodium-restricted diets. (These should be avoided regardless. Among inpatients, sodium-restricted diets promote malnutrition and don't affect volume status). (Mai et al. 2023)
  • Consider early and aggressive enteral nutrition for intubated patients to avoid volume depletion.
    • Intravenous maintenance fluids are generally unhelpful, but enteral maintenance nutrition is beneficial.

[3] Use enteral resuscitation fluid when able

  • Enteral fluid resuscitation is appropriate in the absence of:
    • NPO is genuinely required (e.g., for a procedure).
    • Obvert gastrointestinal dysfunction (e.g., ileus, obstruction, active GI hemorrhage, abdominal compartment syndrome, mesenteric ischemia, perforation, high-output fistula).
    • Lack of GI access (e.g., the patient cannot drink and lacks an NG/OG tube).
    • Initial acute resuscitative phase of shock, or very high doses of vasopressors.
  • Many guidelines recommend commercial fluids such as Pedialyte. However, such fluids are often unsuitable for large-volume resuscitation (e.g., Pedialyte contains 45 mM sodium – which is markedly hypotonic).
  • Isotonic enteral resuscitative fluids may be formulated from Soy Sauce, as described below.

[4] Avoid unnecessary use of IV fluids

  • Review the necessity of all IV fluid orders.
  • Avoid maintenance fluid administration except in exceptional situations (e.g., diabetic ketoacidosis, rhabdomyolysis).
  • Avoid discarding any IV fluid bags that have already been spiked (for example, when transitioning from one fluid to a different fluid).
  • Evaluate patients with POCUS before large-volume resuscitation and ensure they are genuinely volume-depleted.
  • Consider earlier use of low-dose vasopressors for patients with vasodilatory shock (e.g., sepsis).

formulation of enteral resuscitation fluid using soy sauce

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There are infinitely many ways to create enteral resuscitation fluid. The following section describes one method for clarity.

Fluid selection & pH-guided fluid resuscitation (8)

why use packets of soy sauce?

  • Soy sauce is a liquid form of high-concentration NaCl (so there is no need to wait while a salt dissolves in water).
  • Soy sauce is strangely palatable. The diluted soy sauce described below tastes surprisingly good (to me at least).
  • Soy sauce is available in pre-measured individual packets, which avoids any infection concerns that could arise from using measuring equipment.
  • Packets of soy sauce are widely available and cheap. Many hospitals may already have these (if they sell sushi or dumplings). Otherwise, you can order them online via Amazon at minimal cost (~4 cents/packet). (NB: I have no conflicts of interest.)

pharmacology of soy sauce

  • One 6-ml packet of soy sauce = 17 mEq NaCl.
  • ⚠️ Don't use low-sodium soy sauce!
  • ⚠️ Calculations performed here are for Kikkoman soy sauce (which contains 960 mg Na per 15 ml). If you're using a different brand with a different sodium concentration, volumes might need to be adjusted accordingly.
  • (Calculations reviewed in the hyponatremia chapter here: 📖)

key concept: the precise tonicity doesn't matter if it's close to isotonic

  • This is honestly a widely misunderstood concept that has been subject to decades of dogma.
  • If a resuscitation fluid has a sodium concentration somewhere around 125-155 mEq/L (roughly isotonic), it will have minimal effect on the patient's sodium concentration. Unless you give the patient an absolutely insane volume of fluid, these small differences in sodium concentration will have a negligible effect on the patient's sodium level. If you need further convincing of this:
    • You can do the math regarding the expected change in sodium per liter (it's tiny).
    • Think about how hard it is to treat hypernatremia (liters of free water!) and how much 3% sodium it takes to increase the sodium level (repeated boluses!).

a brief word on the role of oral resuscitation fluid

  • This isn't intended for emergent treatment of shock.
  • It may be useful for volume resuscitation in patients who can drink or who have enteral feeding tubes.
examples of fluid formulations

500 ml normal saline equivalent

  • Ingredients:
    • 500 ml water.
    • 4 packets of soy sauce.
  • This will create 136 mEq/L NaCl.

1000 ml normal saline equivalent

  • Ingredients:
    • 1000 ml water.
    • 9 packets of soy sauce.
  • This will create 153 mEq/L NaCl.

1000 ml balanced fluid with potassium

  • Ingredients:
    • 1000 ml water.
    • 7 packets soy sauce.
    • 30 mM potassium citrate liquid (may be administered separately to avoid violating medication formulation policies).
  • This will create 149 mEq/L Na, with 30 mEq potassium and 30 mEq alkali.

1000 ml balanced fluid without potassium

  • Ingredients:
    • 1000 ml water.
    • 7 packets soy sauce.
    • 30 mM sodium citrate liquid (aka BICITRA; may be administered separately to avoid violating medication formulation policies).
  • This will create 149 mEq/L Na with 30 mEq/L alkali.

1000 ml balanced fluid with sodium bicarbonate tabs

  • Ingredients:
    • 1000 ml water.
    • 7 packets soy sauce.
    • Four 650-mg tablets of sodium bicarbonate (providing 30 mEq NaHCO3).
  • This will create 149 mEq/L Na with 30 mEq alkali.

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questions & discussion

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To keep this page small and fast, questions & discussion about this post can be found on another page here.

Fluid selection & pH-guided fluid resuscitation (10)

  • Don't use normal saline as your default resuscitative fluid. There are many reasons for this, but one salient one is as follows: eventually you will wind up giving liters of saline to a hyperkalemic and acidotic patient, thereby pushing them off a pH cliff.
  • Don't be afraid to use Lactated Ringers in patients with hyperkalemia or liver dysfunction. Don't be afraid to use Plasmalyte in any patient (there don't seem to be any legitimate contraindications to Plasmalyte).
  • Don't miss opportunities to fix your patient's pH abnormalities using pH-guided resuscitation (especially for patients with uremic metabolic acidosis).
  • Not understanding how to use various forms of bicarbonate.

Guide to emoji hyperlinks Fluid selection & pH-guided fluid resuscitation (11)

  • Fluid selection & pH-guided fluid resuscitation (12) = Link to online calculator.
  • Fluid selection & pH-guided fluid resuscitation (13) = Link to Medscape monograph about a drug.
  • Fluid selection & pH-guided fluid resuscitation (14) = Link to IBCC section about a drug.
  • Fluid selection & pH-guided fluid resuscitation (15) = Link to IBCC section covering that topic.
  • Fluid selection & pH-guided fluid resuscitation (16) = Link to FOAMed site with related information.
  • Fluid selection & pH-guided fluid resuscitation (17) = Link to supplemental media.

References

  • 24132 Fraley DS, Adler S. Correction of hyperkalemia by bicarbonate despite constant blood pH. Kidney Int. 1977 Nov;12(5):354-60. doi: 10.1038/ki.1977.122 [PubMed]
  • 01552710 Blumberg A, Weidmann P, Ferrari P. Effect of prolonged bicarbonate administration on plasma potassium in terminal renal failure. Kidney Int. 1992 Feb;41(2):369-74. doi: 10.1038/ki.1992.51 [PubMed]
  • 01668124 Gutierrez R, Schlessinger F, Oster JR, Rietberg B, Perez GO. Effect of hypertonic versus isotonic sodium bicarbonate on plasma potassium concentration in patients with end-stage renal disease. Miner Electrolyte Metab. 1991;17(5):297-302. [PubMed]
  • 09568658 Lorenzo M, Davis JW, Negin S, Kaups K, Parks S, Brubaker D, Tyroch A. Can Ringer's lactate be used safely with blood transfusions? Am J Surg. 1998 Apr;175(4):308-10. doi: 10.1016/s0002-9610(98)00011-7 [PubMed]
  • 10793162 Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, Wheeler A. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000 May 4;342(18):1301-8. doi: 10.1056/NEJM200005043421801 [PubMed]
  • 14718447 Kellum JA, Song M, Venkataraman R. Effects of hyperchloremic acidosis on arterial pressure and circulating inflammatory molecules in experimental sepsis. Chest. 2004 Jan;125(1):243-8. doi: 10.1378/chest.125.1.243 [PubMed]
  • 15845718 O'Malley CM, Frumento RJ, Hardy MA, Benvenisty AI, Brentjens TE, Mercer JS, Bennett-Guerrero E. A randomized, double-blind comparison of lactated Ringer's solution and 0.9% NaCl during renal transplantation. Anesth Analg. 2005 May;100(5):1518-24, table of contents. doi: 10.1213/01.ANE.0000150939.28904.81 [PubMed]
  • 18569935 Khajavi MR, Etezadi F, Moharari RS, Imani F, Meysamie AP, Khashayar P, Najafi A. Effects of normal saline vs. lactated ringer's during renal transplantation. Ren Fail. 2008;30(5):535-9. doi: 10.1080/08860220802064770 [PubMed]
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