Controversies in fluid therapy: Type, dose and toxicity

Abstract

Fluid therapy is perhaps the most common intervention received by acutely ill hospitalized patients; however, a number of critical questions on the efficacy and safety of the type and dose remain. In this review, recent insights derived from randomized trials in terms of fluid type, dose and toxicity are discussed. We contend that the prescription of fluid therapy is context-specific and that any fluid can be harmful if administered inappropriately. When contrasting ''crystalloid vs colloid'', differences in efficacy are modest but differences in safety are significant. Differences in chloride load and strong ion difference across solutions appear to be clinically important. Phases of fluid therapy in acutely ill patients are recognized, including acute resuscitation, maintaining homeostasis, and recovery phases. Quantitative toxicity (fluid overload) is associated with adverse outcomes and can be mitigated when fluid therapy based on functional hemodynamic parameters that predict volume responsiveness and minimization of non-essential fluid. Qualitative toxicity (fluid type), in particular for iatrogenic acute kidney injury and metabolic acidosis, remain a concern for synthetic colloids and isotonic saline, respectively. Physiologically balanced crystalloids may be the ''default'' fluid for acutely ill patients and the role for colloids, in particular hydroxyethyl starch, is increasingly unclear. We contend the prescription of fluid therapy is analogous to the prescription of any drug used in critically ill patients.© 2014 Baishideng Publishing Group Co., Limited. All rights reserved.Key words: Fluid therapy; Resuscitation; Critical illness; Peri-operative; Toxicity; Saline; Crystalloid; Colloid Core tip: Fluid therapy is exceedingly common in acutely ill patients; however, numerous questions on the efficacy and safety of fluid therapy in terms of the type and dose remain. Fluid therapy prescription is contextspecific and any fluid type can be harmful if administered inappropriately. When considering crystalloids versus colloids, differences in efficacy are modest but the risk of kidney toxicity and bleeding complications with hydroxyethyl starch appear more significant. The differences in chloride load across crystalloid solutions appears to have physiologic and clinically important effects, in particular for contributing to hyperchloremic metabolic acidosis, kidney injury and greater utilization of renal replacement therapy associated with 0.9% saline. Fluid therapy should be viewed as analogous to the prescription of any drug in acutely ill patients.McDermid RC, Raghunathan K, Romanovsky A, Shaw AD, Bagshaw SM. Controversies in fluid therapy: Type, dose and toxicity.

Early Liberal Fluid Therapy for Sepsis Patients Is Not Harmful: Hydrophobia Is Unwarranted but Drink Responsibly

“…Fluid therapy should be treated as any drug which involves consideration of the type, dose, duration of treatment, and toxicity (64). …”

Frequency of Fluid Overload and Usefulness of Bioimpedance in Patients Requiring Intensive Care for Sepsis Syndromes

“…Th ere has been much debate over the use of colloid versus crystalloid solutions for resuscitation. Several studies have failed to identify an advantage in using colloids over crystalloids, with emerging evidence demonstrating increased adverse events including mortality with the use of colloids, particularly hydroxyethyl starch (8,9). Th erefore, isotonic crystalloids, such as 0.9% normal saline, are often the fi rst-line resuscitation fl uids.…”

Guía de práctica clínica para la elección del fluido de restauración volémica perioperatoria en los pacientes adultos intervenidos de cirugía no cardiaca

“…La comprensión de la situación clínica nos ayudará a establecer una mejor indicación del tipo de fluido y cómo lo debemos aplicar 2,16,17 . Las indicaciones para la fluidoterapia en el paciente quirúrgico incluyen 5 conceptos, o «5R», tal como son designadas en la guía clínica de la NICE 5 (tabla 1).…”

“…del tratamiento, la rapidez con la que precisemos restaurar la volemia, el estado hemodinámico y el contexto clínico del paciente 26 . En todo caso, sí es necesario remarcar que la administración de coloides permite una compensación más rápida de la volemia, con un menor volumen y menor potencial de desarrollo de edema tisular que los cristaloides 17,23,59 . Su administración está indicada para la restauración rápida de la volemia, pero sus indicaciones en el perioperatorio de cirugía no cardiaca, así como su dosificación, deben restringirse a las circunstancias que se reflejan en las distintas fichas técnicas de cada uno de los productos.…”