Purpose of review
Significant attention has been recently focused on both maintenance fluid and
resuscitation fluid use in critical care. Accordingly, a focused review of the properties of
crystalloid and colloid fluids, their expected benefits, and potential deleterious side
effects is appropriate and timely.
Recent findings
Despite their ubiquitous use, well described side effects, and ability to be titrated to a
physiologic endpoint, fluids are rarely considered in a fashion similar to other
pharmacologic agents. Understanding their physical and chemical properties allows
the clinician to understand, anticipate and deliberately harness their expected impact on
acidbase balance. Expanded insights into the pathogenesis of common acidbase
disorders may be gleaned from utilizing a physicochemical approach that allows the
precise quantification of the ionic species that impact pH.
Summary
This focused review further enables the clinician to appropriately investigate, modify,
and optimize bedside clinical care related to fluid and acidbase management.
Keywords
acidbase balance, colloids, crystalloids, strong ions, unmeasured ions
Curr Opin Crit Care 16:323331
2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
1070-5295
Introduction
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Na
Cl
Ca
Mg
Lact
Acet
Glucon
pH
mOsm
Plasma
Lactated Ringers
0.9% NSS
Normosol-R
1/2 NSS 75 mEq NaHCO
3
140
130
154
140
152
4
4
0
5
0
100
109
154
98
77
9
2.7
0
0
0
2
0
0
3
0
2
28
0
0
0
0
0
0
27
0
0
0
0
23
0
7.4
6.5
5.5
7.4
var
285295
273
308
280
302
0.9% NSS, normal saline solution; Lact, lactate; Acet, acetate; Glucon, gluconate; mOsm, milliosmoles/l; var, variable as this solution is locally prepared
without pH balancing; pH may be further influenced over time with CO2 equilibration; Plasma, normal human plasma.
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MW/DS
Voluven
HES 130/0.4
Volulyte
Pentastarch
HES130/0.4
HES 200/0.5
Hextend
Hespan
HES 670/0.7
HES 670/0.7
Concentration
6%
10%
6%
6%
10%
6%
6%
Diluent
C2/C6
NSS
9:1
Balanced solution
NSS
6:1
5:1
Balanced solution
NSS
4.5 : 1
4.5 : 1
DS, degree of substitution; HES, hydroxyethyl starch; MW, molecular weight in kiloDaltons (kDa); NSS, 0.9% normal saline solution. Note: not all
colloids are available in the US. Food and Drug Administration approved colloids are indicated by ( ).
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Dextrans
Dextrans are fairly homogeneous preparations of D-glucose polymers principally joined by a-1,6 bonds creating
linear macromolecules that are characterized by their
concentration into two commercially available preparations, Dextran 40 (molecular weight avg 40kDa)
and Dextran 70 (molecular weight avg 70kDa) [14].
The glucose moieties are derived from enzymatic cleavage of sucrose generated by Leuconostoc bacteria utilizing
dextran sucrase yielding high molecular weight detrains
that are modified into the final product using acid
hydrolysis and ethanol-based fractionation processes.
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infused fluid:
Hypernatremia
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(4) Asymptomatic chronic hypernatremia should be corrected at a rate not exceeding 0.5 mEq/l per hour, and
not more than 10mEq/l over 24 h.
Intravenous free water, commonly provided as D5W, is
most commonly used but may be supplemented by
gastrointestinal luminal free water using either pure
water, or diluted tube feeds. The same formula used
for correcting hyponatremia may be used to calculate free
water deficit:
D Na infusate Na infusate K
serum Na=Total body water 1
For example, administration of 1 l of D5W to a 70 kg man
with a serum Na of 160 would result in a decrease of
3.7 mEq/l assuming no loss of water.
Hypokalemia
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to note that the loss of weak acid (ATOT) is an alkalinizing process [23]. However, the critically ill are only
infrequently alkalemic despite often profound hypoalbuminemia. This seemingly counterintuitive observation is understood by recalling that the SID and
ATOT are best evaluated in relation to one another
rather than as absolute values. Hypoalbuminemic
patients often also manifest a reduced SID, perhaps
as compensation for their reduced ATOT from hypoalbuminemia [24,25].
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3
Conclusion
It is important to remember that intravenous fluids are
drugs. They should be prescribed with care and with
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