The History & Practice of IV Fluid Therapy –have we advanced in 185 years?

Liam Plant

Clinical Professor of Renal MedicineUniversity College Cork

Consultant Renal PhysicianCork University Hospital

National Clinical DirectorHSE National Renal Office

The Chimes at Midnight….

Halite

Salt & Water

Living on LandScarcity & Plenty

Biological response to variation in water intake is rapid

Biological response to sodium depletion is rapid

Too little……

Too much?!!!!!

William Brooke O’Shaughnessy

iv Fluid TherapyUniversity of Edinburgh

‘Blue’ Cholera

Thomas LattaLeith Hospital

1832

Lancet

Classic References

SALINE VENOUS INJECTION IN CASES OF MALIGNANT CHOLERA, PERFORMED WHILE IN THE VAPOUR-BATH.

Thomas Latta

Lancet 1832; 19(480): 193-224

Some Physiological Fluids

Ringer’s Solution 1880’s

Lactated Ringer’s Solution (LRS) 1930’s

Hartmann’s Solution (CSL) 1930’s

Sydney Ringer Alexis Hartmann

Hartog Jacob Hamburger

Utrecht

1896

0.9% Saline

Fluid & Electrolyte requirements

Resuscitation

Routine Maintenance

Replacement

Redistribution

Reassess

Disturbing Case(s)…….

67 yr old femaleCKD3, no proteinuria, hypertension

Elective laparascopic cholecystectomy

5 days laterEWS 8; oedema; pulmonary oedema

AKIN2; hypernatraemia; hypokalaemiaBXS -6mmol/l; Lactate 1.1mmol/l;

Why?

Thesis

Disorders of Volume & Tonicity

occur as a consequence of

Fluid management choices

in the ill/injured/post-surgical patient

These, in turn lead to AKI and electrolyte disorders

Who’s in charge……………?

BMJ 2011; 342: d2741

• 30 prospective fluid prescriptions over 24h

• 40% - no fluid status assessment documented

• 17% - no fluid balance chart

• 100% - no weight mentioned in prescription

• 60% - prescription differed from output >1000ml

• 96% - excessive daily sodium prescription

• 80% - insufficient daily potassium prescription

Soc Critical Care Anaes 2012; 114: 640-51.

GD, fluid-restrictive, fluid-liberal

• GD: reduced compared with non-GDrenal complications, pneumonia, time to 1st bowel movement, resumption of normal diet, LOS

• FR: reduced compared with FLpulmonary oedema, pneumonia, time to 1st bowel movement, LOS

• GD & FL: increased crystalloid intake; different outcomes

Into the Darkness……………

Necessary Tetrad

Water

Sodium

Chloride

Potassium

Dumbed-down Duo

‘How much fluid?’

‘How much potassium?’

Response to Injury

Sodium retention phase

Sodium diuresis phase

Avoid pre-operative/perioperative/postoperative hypovolaemia

BUT NOT AT COST OF POST-OPERATIVE

SODIUM, CHLORIDE AND WATER OVERLOAD

Dramatis Personae

Effective renal plasma flowGlomerular filtration rate

CatecholaminesRAASANPAVP

(if Renal Function is normal…………..)

What reduces ability to excrete:

Sodium

• Stress Responsecatecholamines/RAAS/AVP

• Hyperchloraemiarenal vasoconstrictiondecreased GFR

• Catabolismcompetition with ureadecreased urine concentration

• Potassium depletion

• AKI/CKD

Water

• Stress Responsecatecholamines/RAAS/AVP

• Catabolismcompetition with ureadecreased urine concentration

• Urine concentration/dilution

• AKI/CKD

G.I.F.T.A.Su.P.March 2011

http://www.bapen.org.uk/pdfs/bapen_pubs/giftasup.pdf

The British Association for Parenteral andEnteral Nutrition (BAPEN), the Association forClinical Biochemistry, the Association ofSurgeons of Great Britain and Ireland andSociety of Academic and Research Surgery, theRenal Association and the Intensive Care Society.

NICE Guideline CG174December 2013

https://www.nice.org.uk/guidance/cg174/resources/intravenous-fluid-therapy-in-adults-in-hospital-algorithm-poster-set-191627821

Algorithms

1. Assessment

2. Fluid Resuscitation

3. Routine Maintenance

4. Replacement & Redistribution

Bodily Fluids

Composition of commonly used crystalloids

Content Plasma Sodium chloride 0.9%*

Sodium chloride 0.18%/

4% glucose

a

0.45% NaCl/

4% glucose

a

5% glucose

a

Hartmann’s Lactated Ringer’s (USP)

Ringer’s acetate

Alternative balanced solutions for resuscitation**

Alternative balanced solutions for maintenance**

Na+

(mmol/l) 135–145 154 31 77 0 131 130 130 140 40

Cl– (mmol/l) 95–105 154 31 77 0 111 109 112 98 40

[Na+]:[Cl

–]

ratio 1.28–1.45:1 1:1 1:1 1:1 - 1.18:1 1.19:1 1.16:1 1.43:1 1:1

K+ (mmol/l) 3.5–5.3 * * * * 5 4 5 5 13

HCO3 – /

Bicarbonate

24–32

0

0

0

0 29 (lactate) 28

(lactate)

27 (acetate)

27 (acetate)

23 (gluconate)

16 (acetate)

Ca2+

(mmol/l) 2.2–2.6 0 0

0

0 2 1.4 1 0 0

Mg2+

(mmol/l) 0.8–1.2 0 0 0 0 1 1.5 1.5

Glucose (mmol/ l)

3.5–5.5 0 222 (40 g)

222 (40 g)

278 (50 g)

0 0 0 0 0

pH 7.35–7.45 4.5–7.0 4.5 3.5–5.5 5.0–7.0 6–7.5 6–8 4.0–8.0 4.5–7.0

Osmolarity (mOsm/l)

275–295 308 284 278 278 273 276 295 389

* These solutions are available with differing quantities of potassium already added, and the potassium-containing versions are usually more appropriate for meeting maintenance needs.

** Alternative balanced solutions are available commercially under different brand names and composition may vary by preparation.

a The term dextrose refers to the dextro-rotatory isomer of glucose that can be metabolised and is the only form used in IV fluids. However IV fluid bags are often labelled as glucose so only this term

should be used. Traditionally hospitals bought a small range of fluids combining saline (0.18-0.9%) with glucose but several recent NICE/NPSA documents have recommended specific combinations,

which are now purchased to enable guidelines to be followed. Glucose–saline combinations now come in 5 different concentrations, and the addition of variable potassium content expands the pre-mixed

range to 13 different products. Prescribers must therefore specify the concentration of each component; the term dextrose-saline (or abbreviation D/S) is meaningless without these details. What is specified

also impacts significantly on the cost of the product.

Source: This table was drafted based on the consensus decision of the members of the Guideline Development Group.

‘Intravenous fluid therapy in adults in hospital’, NICE clinical guideline 174 (December 2013)

Commonly prescribed fluids

Fluid [Sodium]mmol/l

[Chloride]mmol/l

[Potassium]mmol/l

OsmolaritymOsm/l

5% Dextrose - - - 278

4% Dextrose/0.18

% Saline

30 30 - 283

0.45% Saline 77 77 - 154

Plasma 136-145 98-105 3.5-5.0 280-300

Ringer’s Lactate

130 109 4 273

Hartmann’s 131 111 5 275

4% Gelatine 145 145 - 290

5% Albumin 150 150 - 300

0.9% Saline 154 154 - 308

2 important studies

• Shaw AD, Bagshaw SM, Goldstein SL, et al.Major complications, mortality, and resource utilization after openabdominal surgery: 0.9% saline compared to Plasma-Lyte.

Ann Surg 2012; 255: 821-829.

• Yunos NM, Bellomo R, Hegarty C, et al.Association between a chloride-liberal vs chloride-restrictive intravenousfluid administration strategy and kidney injury in critically ill adults.

JAMA 2012; 308:1566-1572.

Differences

Chloride Liberal

• 2,211 litres 0.9% Saline

• 469 litres Hartmann’s

• 65 litres Plasma-Lyte

• BXS< -5mmol/l: 9%

• BXS> 5mmol/l: 25%

Chloride Restricted

• 52 litres 0.9% Saline

• 3,205 litres Hartmann’s

• 160 litres Plasma-Lyte

• 50% reduction in AKI

• 40% reduction in RRT

• BXS< -5mmol/l: 3%

• BXS> 5mmol/l: 34%

Zhang et al.BMC Nephrology 2013 14:235 doi:10.1186/1471-2369-14-235

Non-AKI AKIN-1 AKIN-2 AKIN-3

Cl0 (mmol/l) 103.4 ± 5.4 103.4 ± 6.6 104.2 ± 6.6 106.7 ± 10.8

Clmax (mmol/l) 107.9 ± 5.4 111.0 ± 7.4 111.7 ± 7.3 115.9 ± 11.0

Clmin (mmol/l) 98.3 ± 5.6 97.3 ± 6.0 97.0 ± 5.2 96.7 ± 8.4

Clmean (mmol/l) 103.4 ± 4.5 103.8 ± 5.5 104.2 ± 5.1 106.7 ± 7.8

JAMA October 27 2015; 314

CARING FOR THE CRITICALLY ILL PATIENT

Effect of a Buffered Crystalloid Solution vsSaline on Acute Kidney Injury Among Patients in the Intensive Care Unit

The SPLIT Randomized Clinical TrialPaul Young, FCICM1,2; Michael Bailey, PhD3; Richard Beasley, DSc1; Seton Henderson, FCICM1,4; Diane Mackle, MN1; Colin McArthur, FCICM1,3,5; Shay McGuinness, FANZCA1,3,6; Jan Mehrtens, RN4; John Myburgh, PhD7,8; Alex Psirides, FCICM2; Sumeet Reddy, MBChB1; Rinaldo Bellomo, FCICM3,9 ; for the SPLIT Investigators and the ANZICS CTG

Assessing Toxicity of Intravenous Crystalloids in Critically Ill Patients

John A. Kellum; Andrew D. Shaw.

Recommendation 1

Because of the risk of inducing hyperchloraemicacidosis in routine practice, when crystalloidresuscitation or replacement is indicated, balancedsalt solutions e.g. Ringer’s lactate/acetate orHartmann’s solution should replace 0.9% saline,except in cases of hypochloraemia e.g. fromvomiting or gastric drainage.

• Evidence level 1b

Recommendation 3

To meet maintenance requirements, adult patientsshould receive sodium 50-100 mmol/day, potassium40-80 mmol/day in 1.5-2.5 litres of water by theoral, enteral or parenteral route (or a combinationof routes). Additional amounts should only be givento correct deficit or continuing losses.Careful monitoring should be undertaken usingclinical examination, fluid balance charts, andregular weighing when possible.

• Evidence level 5

NICE Guideline CG174December 2013

https://www.nice.org.uk/guidance/cg174/resources/intravenous-fluid-therapy-in-adults-in-hospital-algorithm-poster-set-191627821

Algorithms

1. Assessment

2. Fluid Resuscitation

3. Routine Maintenance

4. Replacement & Redistribution

Intravenous 3uid therapy in adults in hospital (CG174)

© NICE 2017. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-

conditions#notice-of-rights).

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Principles and protocols for intravenous " uid therapy

Assessment and monitoring

Intravenous 3uid therapy in adults in hospital (CG174)

© NICE 2017. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-

conditions#notice-of-rights).

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Commonly prescribed fluids

Fluid [Sodium]mmol/l

[Chloride]mmol/l

[Potassium]mmol/l

OsmolaritymOsm/l

5% Dextrose - - - 278

4% Dextrose/0.18

% Saline

30 30 - 283

0.45% Saline 77 77 - 154

Plasma 136-145 98-105 3.5-5.0 280-300

Ringer’s Lactate

130 109 4 273

Hartmann’s 131 111 5 275

4% Gelatine 145 145 - 290

5% Albumin 150 150 - 300

0.9% Saline 154 154 - 308

Thank You