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Fluid Resuscitation in Critically Ill Patients

23 May 2019 9:12 AM | Deleted user

Author:  Ivan Porto, 2020 PharmD Candidate
Mentor: Paul Juang, PharmD, BCPS, BCCCP, FASHP, FCCM; Professor, Department of Pharmacy Practice
St. Louis College of Pharmacy

Introduction

The Surviving Sepsis Campaign (SSG) 2016 makes several recommendations about fluid resuscitation. The current SSG recommendations state that at least 30 mL/kg of IV crystalloid should be given to patients within the first 3 hours of admission, with a target MAP of 65 mmHg.1  Reassessment of these patients should include the evaluation of several hemodynamic parameters, including heart rate, blood pressure or the use of other dynamic parameters.2  After initial resuscitation, SSG recommends that crystalloids should be used for subsequent intravascular volume replacement1 (strong recommendation) and that albumin should be added when patients require large amounts of crystalloids (weak recommendation).

However, one area that lacks a definitive recommendation is which crystalloids to use in different situations. The current SSG is unable to recommend one crystalloid solution over another because no direct comparisons have been made between isotonic saline and balanced salt solution in patients with sepsis.1  Furthermore, the SSG fails to address which fluids to use in non-septic critically ill patients.

When providing IV fluid resuscitation for critically ill patients, the primary goal is for fluids to be given in a fashion that maximizes positive healthcare outcomes. Recent trials have provided insight into the advantages and disadvantages of several IV fluids, which can help direct deciding which fluid to use in patients being held in an ICU.

Normal Saline vs. Balanced Crystalloids

Balanced Crystalloids versus Saline in Critically Ill Adults (SMART) This trial compared normal saline and balanced crystalloids for use in the fluid resuscitation of critically ill patients.

* Decision to use lactated ringer’s vs Plasma-Lyte depended on the preference of the treating physician

Balanced Crystalloids versus Saline in Noncritically Ill Adults (SALT-ED) This trial compared normal saline and balanced crystalloids for use in the fluid resuscitation of non-critically ill patients.

* Decision to use lactated ringer’s vs Plasma-Lyte depended on the preference of the treating physician

Summary of Results


Take home points:

  • No difference in rate of death, but evidence suggests that balanced crystalloids are overall superior in end organ damage for patients who survive their ICU stay.
    • Lactated Ringer’s is superior to normal saline in patients with sepsis.
  • Due to the millions of patients treated with IV crystalloids per year, a number needed to treat of 111 in regards to renal dysfunction suggests that balanced crystalloids are superior to NS.7 However, this data is limited to non-critically ill patients.

Crystalloids vs Colloids

A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit (SAFE) This trial compared 4% albumin and normal saline for use in the fluid resuscitation of critically ill patients.

Albumin Replacement in Patients with Severe Sepsis or Septic Shock (ALBIOS) This trial compared 20% albumin combined with crystalloids to crystalloids alone for use in the fluid resuscitation of patients with sepsis.

Crystalloids vs. colloids for fluid resuscitation in the Intensive Care Unit: A systematic review and meta-analysis A systematic review of 55 articles, published in 2019, examining the comparison between crystalloids and colloids for the fluid resuscitation of ICU patients.

Summary of Results

Take home points:

  • There is no difference in risk of death between crystalloids and albumin within the first month of treatment5,7,8
    • Albumin should not be used in patients with traumatic brain injury (weak recommendation, limited evidence)8
  • Crystalloids are useful, but care needs to be taken on preventing fluid overload. The majority of the crystalloids’ disadvantages stem from their overuse.
    • Liberal use of crystalloids will lead to third spacing, which will complicate treatment for critically ill patients. Patients should be examined in a detailed manner to assess their response to fluid resuscitation. This includes, but is not limited to, heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output.6
  • Starting with crystalloids and switching to colloids “when patients require substantial amounts of crystalloids”. However, there is no clear recommendation to guide physicians on what constitutes a “substantial amount”.5
    • The authors suggest a maximum of 3-4L of crystalloids, but do not provide citation. They also suggest estimating with fluid input/output volumes, but state it is unreliable. Furthermore, the authors suggest that bioelectrical impedance analysis may provide usefulness in the future.5
  • Using dynamic measures (passive leg raises, variations in systolic pressure and pulse pressure) instead of CVP to monitor response to fluid resuscitation and guide further therapy.1,5
  • Colloids provides no advantage in risk of death. However, in general, they do provide an advantage in end organ damage with the exception of hepatotoxicity and coagulopathy.7
  • Albumin is significantly more expensive than crystalloids. Being able to raise CVP more effectively, and thus being able to discontinue other vasopressors earlier, could offset that cost. However, need for more PRBC could add to the cost.7,8
    • Cost benefit analysis could be performed in the future
  • No suggestions could be made on different concentrations of albumin fluids.
  • Hydroxyethyl starch – While it was a part of the colloid category, it was shown to have clear disadvantages vs other fluids (strong evidence).1,5
  • Dextran & Gelatin – These are not preferred.5,6

References:

  1. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017 Mar;43(3):304-377. Doi: 10.1007/s00134-017-4683-6.
  2. Rivers E, Nguyen B, Havstad S, et al. Early Goal-Directed Therapy Collaborative Group: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J med 2001; 345:1368-1377.
  3. Self W, Semler M, Wanderer JP, et al. Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med. 2018 Mar 1;378(9):819-828. Doi: 10.1056/NEJMoa1711586.
  4. Semler M, Self W, Rice T. Balanced Crystalloids vs Saline for Critically Ill Adults. N Engl J Med. 2018 May 17;378(2):1951. doi: 10.1056/NEJMc1804294
  5. Martin GS, Bassett P. Crystalloids vs. colloids for fluid resuscitation in the Intensive Care Unit: A systematic review and meta-analysis. J Crit Care. 2019 Apr;50:144-154. Doi: 10.1016/j.crc.2018.11.031.
  6. Moeller C, Fleischmann C, Thomas-Reuddel D, et al. How safe is gelatin? A systematic review and meta-analysis of gelatin-containing plasma expanders vs crystalloids and albumin. J Crit Care. 2016; 35:75-83.
  7. Caironi P, Tognoni G, Masson S, et al. Albumin replacement in patients with severe sepsis or septic shock. N Engl J Med. 2014 Apr 10;370(15):1412-21. doi: 10.1056/NEJMoa1305727.
  8. Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004 May 27;250(22):2247-56.


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