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"Fluid resuscitation with large quantities of high chloride containing fluids are shown to increase the incidence of AKI , hyperchloremic normal anion gap metabolic acidosis and mechanical ventilation times,thereby poor outcomes"
fluids for resuscitation in critically ill patients is a controversial topic.Multiple RCT'S have shown harmful effects of hydroxy ethylstarchs.Having said that,fluids are the cornerstone for capillary recruitment in microcirculatory dysfunction syndrome to maintain adequate capillary driving forces .current evidence support crystalloids over colloids for fluid resuscitation in critically ill patients.There is insufficient data or RCT's comparing Normal Saline vs RL (Crystalloids) and also High chloride vs Low chloride containing fluids for resuscitation.Most of these studies are retrospective, prospective or observational with variable quality ,selection bias and some RCT's with small sample size with conflicting results making it more complicated .
"Hunt for Near Ideal Resuscitation Fluid continues...................."
There are no
ReplyDeletelarge-scale RCT's comparing 0.9% saline with
balanced crystalloids. Some balanced crystalloids are
hypo-osmolar and may not be suitable for neurosurgical
patients because of their propensity to cause brain edema.
Saline may be the solution of choice used for the
resuscitation of patients with alkalosis and hypochloremia.
Nevertheless, there is evidence to suggest that balanced
crystalloids cause less detriment to renal function than 0.9%
saline, with perhaps better clinical outcome.
Hence, its debatable
that chloride-rich crystalloids such as 0.9% saline should be
replaced with balanced crystalloids as the mainstay of fluid
resuscitation to prevent ‘pre-renal’ AKI and the need for RRT.
In a recent issue of Critical Care, 0.5 M sodium lactate infusion for 24 hours was reported to increase cardiac output in patients with acute heart failure. This effect was associated with a concomitant metabolic alkalosis and a negative water balance. Growing data strongly support the role of lactate as a preferential oxidizable substrate to supply energy metabolism leading to improved organ function (heart and brain especially) in ischemic conditions. Due to its sodium/chloride imbalance, this solution prevents hyperchloremic acidosis and limits fluid overload despite the obligatory high sodium load. Sodium lactate solution therefore shows many advantages and appears a very promising means for resuscitation of critically ill patients. Further studies are needed to establish the most appropriate dose and indications for sodium lactate infusion in order to prevent the occurrence of severe hypernatremia and metabolic alkalosis.
ReplyDeleteCourtesy: Critical Care 2014, 18:163
i would like more inputs regarding this Sodium lactate resuscitation
Sodium lactate is the sodium salt of lactic acid.Hartmann's solution or compound sodium lactate is a crystalloid solution that is most closely isotonic with blood. It is especially suitable when the losses result in too much acid being present in the blood and is very similar—though not identical—to lactated Ringer's solution, the ionic concentrations of which differ.One litre of Hartmann's solution contains:
Delete131 mEq of sodium ion = 131 mmol/L.
111 mEq of chloride ion = 111 mmol/L.
29 mEq of lactate = 29 mmol/L.
5 mEq of potassium ion = 5 mmol/L.
4 mEq of calcium ion = 2 mmol/L.
This amounts to an osmolarity of 279 mOsm/L
On the other hand,One litre of Ringers Lactate solution contains:
130 mEq of sodium ion = 130 mmol/L
109 mEq of chloride ion = 109 mmol/L
28 mEq of lactate = 28 mmol/L
4 mEq of potassium ion = 4 mmol/L
3 mEq of calcium ion = 1.5 mmol/L
Ringers Lactate has an osmolarity of 273 mOsm/L
The lactate is metabolized into bicarbonate by the liver, which can help correct metabolic acidosis.one problem with infusions of large quantities of sodium lactate is possibility of hypernatremic alkalosis contrary to hyperchloremic metabolic acidosis with Normal saline resuscitation
Hardly there are any studies supporting sodium lactate use for resuscitation in a properly conducted randomised fashion other than few in dengue shock syndrome,burns and some cardiac surgery patients.Its too premature to draw any strong conclusion of its use as a near ideal resuscitation fluid ,provided its use is evident by properly conducted large RCT's .More research is needed ..............................................
DeleteThere is a beautiful article on resuscitation fluids published in nejm Sep 2013.follow this link for more information .http://www.nejm.org/doi/pdf/10.1056/NEJMra1208627
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