Intravenous (IV)

Hypovolemic Hyponatremia (see Hyponatremia)

• Clinical Efficacy
  • Single-Center, Multiple-Crossover SALT-ED Trial of Balanced Crystalloids vs Normal Saline in Non-Critically Ill Adults in the Emergency Department (NEJM, 2018) [MEDLINE]: n = 13,347
    • Among noncritically ill adults treated with intravenous fluids in the emergency department, there was no difference in hospital-free days between treatment with balanced crystalloids and treatment with saline

Anaphylaxis (see Anaphylaxis)

• Clinical Efficacy

Hemorrhagic Shock (see Hemorrhagic Shock)

• Clinical Efficacy

Hypovolemia/Hypovolemic Shock (see Hypovolemic Shock)

• Clinical Efficacy
  • Single-Center, Multiple-Crossover SALT-ED Trial of Balanced Crystalloids vs Normal Saline in Non-Critically Ill Adults in the Emergency Department (NEJM, 2018) [MEDLINE]: n = 13,347
    • Among noncritically ill adults treated with intravenous fluids in the emergency department, there was no difference in hospital-free days between treatment with balanced crystalloids and treatment with saline

Sepsis (see Sepsis)

• Clinical Efficacy
  • Cluster-Randomized, Multiple-Crossover SMART-MED and SMART-SURG Trial of Balanced Crystalloids vs Normal Saline in Critically Ill Adults (NEJM, 2018) [MEDLINE]: n = 7942 (5 ICU’s)
    • Balanced Crystalloids (Lactated Ringers or Plasma-Lyte) for Intravenous Fluid Resuscitation Decreased the Composite Outcome of All-Cause Mortality Rate, Need for New Renal Replacement Therapy, and Persistent Renal Dysfunction, as Compared to Normal Saline

Subcutaneous (SQ)

• Hypovolemic Shock (see Hypovolemic Shock)

Other

• Nasal Irrigation: in the setting of sinusitis
• Ocular Irrigation: in the setting of ocular exposures
• Wound Irrigation: does not burn or sting when used

Definitions

• Crystalloids: sodium-based electrolyte solutions

History of Crystalloids

• 1831 (Europe): first clinical use of crystalloids during the India Blue Cholera pandemic
• 1896 (Holland): Hartog Hamburger (Dutch physiologist) invented “normal saline”: he intended to use this fluid in the in vitro study of erythrocyte lysis
• 1880 (England): Sydney Ringer invented “Ringer’s solution”: he used this fluid to sustain contractility in isolated frog hearts
  • The fluid was inadvertently made with tap water (instead of distilled water) and the inadvertent presence of calcium likely led to the experiment being successful
  • Ringer analyzed the fluid and found that it contained calcium, sodium, potassium, chloride, and magnesium
• 1930’s (USA): pediatrician Alexis Hartmann added lactate to a solution very similar to Ringer’s solution, creating a forerunner of “Lactated Ringer’s” (see Lactated Ringers): lactate was added by Hartmann to “buffer” the solution (creating a “balanced” solution)

Balanced vs Unbalanced Crystalloids

• Balanced Crystalloids: mildly hypotonic lactate or acetate buffered solutions (with signficantly lower chloride concentrations than saline)
  • Lactated Ringer’s (LR) (see Lactated Ringers)
  • Acetate Ringer’s
  • Hartmann Solution
  • Plasma-Lyte (from Baxter Healthcare)
• Unbalanced Crystalloids : contain no buffer (note: additionally, normal saline has higher chloride concentration than the above)
  • Normal Saline (NS): 0.9% NaCl
  • Half Normal Saline (see Half Normal Saline): 0.45% NaCl
  • Quarter Normal Saline (see Quarter Normal Saline): 0.22% NaCl
  • Dextrose 5% in Water (D5W) (see Dextrose 5% in Water): Dextrose 5%
  • D5 Normal Saline (D5NS): Dextrose 5% + 0.9% NaCl
  • D5 Half Normal Saline (D5 1/2NS): Dextrose 5% + 0.45% NaCl
  • D5 Quarter Normal Saline (D5 1/4NS): Dextrose 5% + 0.22% NaCl
• Comparative Data
  • Use of balanced crystalloid is associated with decreased kidney pathology in rat model of hemorrhagic shock, as compared to unbalanced crystalloid [MEDLINE]
  • Chloride-restrictive IV fluid resuscitation strategy is associated with decreased renal injury [MEDLINE]: may be related to hyperchloremia’s induction of renal vasoconstriction

Composition of Various Intravenous Fluids

• Normal Saline Has a Slightly Higher Osmolarity than Serum (Serum Osmolarity is Approximately 280-310 mOsm/L): however, taking into account the osmotic coefficient (which corrects for non-ideal solutions), normal saline is close to isotonic with blood

Cardiovascular Adverse Effects

• Congestive Heart Failure/Fluid Overload (see Congestive Heart Failure)

Renal Adverse Effects

• Hyperchloremic Non-Anion Gap Metabolic Acidosis [MEDLINE] (see Metabolic Acidosis-Normal Anion Gap)
  • Mechanism: likely involves narrowing of strong ion difference between sodium and chloride
• Hypernatremia (see Hypernatremia)

Other Adverse Effects

• Exacerbation of Cirrhotic Ascites (see Ascites)