Crystalloid Fluids


Article Author:
Eric Epstein


Article Editor:
Muhammad Waseem


Editors In Chief:
Russell McAllister
Jason Widrich
Daniel Sizemore


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James Hughes
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Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
5/30/2019 8:44:41 PM

Indications

Crystalloid fluids are a subset of intravenous solutions that find frequent use in the clinical setting. Crystalloid fluids are the first line choice for fluid resuscitation in the presence of hypovolemia, hemorrhage, sepsis, and dehydration. Further clinical applications include acting as a solution for intravenous medication delivery, to deliver maintenance fluid in patients with limited or no enteral nutrition, blood pressure management, and to increase diuresis to avoid nephrotoxic drug or toxin-mediated end-organ damage.

While normal saline (0.9% NaCl Solution) is the most frequently used crystalloid fluid, many other formulations can provide improved clinical outcomes in specific patient populations.

Other commercially available crystalloid fluids include:

  • Lactated Ringers/Hartman's Solution (lactate buffered solution)
  • Acetate buffered solution
  • Acetate and lactate buffered solution
  • Acetate and gluconate buffered solution
  • 0.45% NaCl (hypotonic solution)
  • 3% NaCl (hypertonic solution)
  • 5% Dextrose in water
  • 10% Dextrose in water

Mechanism of Action

A crystalloid fluid is an aqueous solution of mineral salts and other small, water-soluble molecules. Most commercially available crystalloid solutions are isotonic to human plasma. These fluids approximate concentrations of various solutes found in plasma and do not exert an osmotic effect in vivo. Crystalloid fluids function to expand intravascular volume without disturbing ion concentration or causing large fluid shifts between intracellular, intravascular, and interstitial spaces.

Hypertonic solutions such as 3% saline solutions contain higher concentrations of solutes than those found in human serum. Because of this discrepancy in concentration, these fluids are osmotically active and therefore will cause fluid shifts. Their primary indication is for emergent replacement of serum solutes, such as in hyponatremia with neurologic symptoms.

Buffered solutions contain molecules that metabolize in vivo to bicarbonate. These solutions were designed to sustain a normal physiologic plasma pH. The three commonly used molecules are lactate, acetate, and gluconate. Lactate and gluconate are hepatically metabolized to bicarbonate while acetate is predominantly metabolized peripherally by skeletal muscle.

Administration

Crystalloid fluids are administered parenterally via an intravenous infusion. Infusion rates depend on the clinical presentation and indication for administration.

Fluid Resuscitation:

In an acute setting, rapid infusion of crystalloid fluids may be indicated. In this setting, it may require a pressure apparatus to the bag of fluid to achieve a higher infusion rate. In this clinical setting, larger bore intravenous cannulas should be used to ensure safe administration of high fluid volumes. Fluids should be administered preferably via large-bore peripheral lines (18-gauge or larger) or through a central access, which may also be used for delivery of blood products if required.

In 2012, the Surviving Sepsis Campaign guidelines recommended Early Goal-directed therapy (EGDT) as the standard of care in managing patients in septic shock. These guidelines dictated that patients receive empirically dosed rapid volume resuscitation. Patients should receive a fluid challenge of 20 mL/kg over the first 30 minutes of treatment. Subsequent volume dosing should depend on the severity of hypovolemia and should be adjusted in increments of 500 mL, aiming for an ultimate central venous pressure of 8-12 mmHg.[1] However, revised guidelines in 2018 have called into question the efficacy of EGDT. The revised guidelines now state that fluid provision should be in a 1-hour bundle by administering 30 mL/kg crystalloid for hypotension or lactate = 4 mmol/L. This guideline has a rating of 'strong recommendation.'

Maintenance Fluids:

The fluid requirements of patients were determined to be related to a patient’s caloric demand by Drs. Holliday and Segar in 1957.[2] Since this time, their initial formula has been modified to provide clinicians with guidelines for administration of maintenance crystalloid fluids. The mass-based formula uses what is known as the “4-2-1” rule:

  • 0-10 kg: +4 mL/kg/hr
  • 10-20 kg: +2 mL/kg/hr
  • >20 kg: +1 mL/kg/hr

Example: 100kg patient: 20 kg (40 + 20 mL/hr) + 80 kg (80 mL/hr) = 140 mL/hr

Additional formulas for fluid administration have been developed for specific clinical scenarios (e.g., the Parkland Formula for fluid maintenance in burn patients).

Adverse Effects

Volume expansion with crystalloid fluids may cause iatrogenic fluid overload. The risk of this complication is particularly elevated in patients with impaired kidney function (acute kidney injury, chronic kidney disease, etc.) and these patients should, therefore, receive treatment with judicious use of intravenous fluids. Patients with congestive heart failure are at elevated risk for serious adverse effects of crystalloid fluid administration. Fluid overload can cause life-threatening pulmonary edema and the worsening of a diastolic or systolic heart failure, leading to end-organ damage or even death. It is vital for the clinician to monitor these patients carefully and to administer the minimum required volume to maintain volume homeostasis.

Normal Saline (0.9% Saline)

Normal saline has a higher concentration of chloride ions (154 mmol/L) than is found in human serum (98-106 mmol/L). With the administration of large volumes of normal saline, hyperchloremia occurs. While there is still some debate on the exact mechanism of this pH disturbance, the thinking is that the increase in chloride concentration adjusts the strong ion difference in plasma, resulting in more free water in the intravascular space. As a result, the hydrogen ion concentration in the serum would increase to maintain electrochemical neutrality. Excessive renal bicarbonate excretion can occur, resulting in metabolic acidosis.[3] The dilution of serum bicarbonate through non-buffered crystalloids (e.g., normal saline) may also contribute to acidosis. Besides metabolic acidosis, clinical research has shown that high volumes of normal saline can cause hyperchloremia-induced renal afferent arteriole constriction, which can cause a decrease in the glomerular filtration rate.[4] 

Acetate buffered crystalloid solutions have been the subject of much debate in the medical literature. Studies performed on dogs have shown that even small volumes of acetate containing crystalloids can significantly increase the serum concentration of acetate to 10-40 times the physiologic level. Some suggest that acetate may potentiate hemodynamic instability via decreasing both myocardial contractility and blood pressure.[5] 

Unlike acetate buffered solutions, lactated crystalloid fluids have the potential to induce hyperglycemia. Lactate is a metabolically active compound that is utilized during the gluconeogenesis to produce glucose. Hence, excessive administration of lactated crystalloids may be of concern in diabetic patients.[5]

Contraindications

Crystalloid fluids should not be administered to patients who are fluid-overloaded. Special care is prudent when administering fluids to patients with congestive heart failure or those with significant renal impairment (e.g., CKD-V dialysis-dependent patients).

Hypertonic saline is contraindicated in all clinical settings except in patients with severe hyponatremia and neurologic sequelae. Rapid correction of hyponatremia may cause central pontine myelinolysis, a devastating neurologic condition.

Hypotonic solutions are also contraindicated in patients with or at risk of developing cerebral edema.

Crystalloids containing potassium (Lactate ringers, Hartman’s solution, etc.) are relatively contraindicated in hyperkalemic patients since these may exacerbate their condition which in turn can lead to ventricular dysrhythmias.

Crystalloids containing dextrose (D5%W, D10%W, D5% 0.45% NS, etc.) should be avoided in patients with hyperglycemia.

Ringer Lactate solution contains calcium ions. Calcium can induce coagulation of the blood products in the IV tubing and therefore inhibit their effective delivery. In patients who require a blood transfusion, blood products should utilize a separate IV setup.

Monitoring

Patients should undergo assessment for signs and symptoms of dehydration and fluid overload. Indications that a patient may receive inadequate volume include elevated lactate and creatinine concentrations in the absence of an alternate cause. The urine output should be monitored. An ideal urine output target of 0.5 mL/kg/hr indicates adequate hydration but may not be useful to assess volume status in patients with renal impairment.

To monitor for fluid overload, patients at high risk of developing this complication should receive frequent re-evaluation. Providers should assess for new or worsening crackles. These sounds may indicate pulmonary edema secondary to volume overload. Additionally, any new or worsening peripheral edema in the extremities is also a potential indication of excessive crystalloid fluid administration.

In patients receiving hypertonic saline for severe hyponatremia with neurologic sequelae, frequent neurologic checks should be performed to assess for clinical improvement. Such monitoring can also help to identify worsening neurologic function as a potential indicator of cerebral edema or central pontine myelinolysis.

Patients receiving large volumes of crystalloid fluids should be monitored for electrolyte imbalances caused by crystalloid fluid administration.

Enhancing Healthcare Team Outcomes

IV fluids are commonly administered during resuscitation. Broadly, IV fluids can fall into two separate categories: crystalloids and colloids. In most clinical settings, crystalloids are the choice of fluid for many indications for fluid resuscitation, maintenance, or as a solvent for medication delivery.

The 2018 sepsis guidelines from the Surviving Sepsis Campaign have suggested the initiation of treatment with crystalloid fluids. However, they do not make recommendations regarding which fluid should is the best choice. According to their recommendations, fluids should be aggressively administered at a rate of 30 ml/kg in the first hour in a setting of hypotension or a lactate concentration greater than 4mmol/L [Evidence Level II].[6]

 Established guidelines for crystalloid fluid under various clinical conditions are not yet extant. The SMART and SMART-SURG trials demonstrated a decreased rate of AKI, but not overall survival among critically ill patients, who received  Ringer's lactate, a balanced, lactate-buffered crystalloid over normal saline [Evidence Level I].[7]


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Crystalloid Fluids - Questions

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Which of the following is not a crystalloid fluid?



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Which of the following is not a crystalloid solution?



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Which intravenous fluid most closely resembles the electrolyte concentrations in plasma?



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The most common crystalloids for intravenous infusion in hospitals are which of the following? Select all that apply.



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A 76-year-old female presents to the emergency department with vital signs of temperature 101.3 F, heart rate 115 bpm, blood pressure 105/62 mmHg, respiratory rate 16/minute, and pulse oximetry 98% on room air. The patient is altered and unable to provide a substantial history. Family members report that the patient lives in an assisted living facility that has recently had a large outbreak of pneumonia. They report that the patient has no history of cardiac or renal pathology. Code sepsis is activated per the emergency department. Blood cultures are drawn, and empiric antibiotic therapy is initiated. Per the Surviving Sepsis Campaign's 2018 updated guidelines, how much volume should be administered in the first bundle?



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A 17-year-old male presents to the emergency department complaining of hours of headache, abdominal pain, nausea, vomiting, and lack of energy. The patient reports he has never felt this way before now. The patient has no past medical history, takes no medications, does not smoke, drink, or abuse illicit drugs. On physical exam, he is an ill-appearing, thin male that is breathing rapidly with generalized abdominal tenderness to palpation without rebound or guarding. Point of care glucose results at 685 mg/dL and a venous blood gas demonstrates a pH of 7.2 with an anion gap of 30 mEq/L. The intern assigned to the case orders an insulin drip at a dose of 0.1 units/kg. He also initiates crystalloid fluids and administers 4 liters of normal saline over the next few hours. After being admitted to the hospital and receiving continued treatment, the patient's anion gap has closed, but he remains acidotic. What is the most likely iatrogenic cause of his persistent acidosis?



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A 17-year-old female presents to the emergency department brought in by ambulance after being struck by a car traveling at high velocity while she was crossing the street. The patient had loss of consciousness. Vital signs are as temperature 98.2 F, heart rate 125 bpm, blood pressure 90/60 mmHg, respiratory rate 18/minute, and pulse oximetry 96% on a non-rebreather mask. A trauma code is activated, and the patient is quickly undressed. The initial assessment finds an intact airway with decreased breath sounds on the left and decreased left pedal pulses. The patient is intubated, and a chest tube is placed on the left. More than 600 cc of blood drains from the left thoracostomy tube. On secondary survey, the patient's left leg is shortened, and there is profound pelvic instability. The patient was started on lactated Ringer's solution in the field via an 18 gauge intravenous line in the right antecubital fossa. The trauma team activates the hospital's rapid transfusion protocol but is unable to establish additional peripheral access. While the team works to gain central venous access, what measure should be taken to prepare the 18 gauge IV for blood product transfusion?



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Crystalloid Fluids - References

References

Boyd JH,Forbes J,Nakada TA,Walley KR,Russell JA, Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Critical care medicine. 2011 Feb     [PubMed]
Chesney CR, The maintenance need for water in parenteral fluid therapy, by Malcolm A. Holliday, MD, and William E. Segar, MD, Pediatrics, 1957;19:823-832. Pediatrics. 1998 Jul     [PubMed]
Eisenhut M, Causes and effects of hyperchloremic acidosis. Critical care (London, England). 2006     [PubMed]
Chang R,Holcomb JB, Choice of Fluid Therapy in the Initial Management of Sepsis, Severe Sepsis, and Septic Shock. Shock (Augusta, Ga.). 2016 Jul     [PubMed]
Reddy S,Weinberg L,Young P, Crystalloid fluid therapy. Critical care (London, England). 2016 Mar 15     [PubMed]
Levy MM,Evans LE,Rhodes A, The Surviving Sepsis Campaign Bundle: 2018 update. Intensive care medicine. 2018 Jun     [PubMed]
Semler MW,Self WH,Wanderer JP,Ehrenfeld JM,Wang L,Byrne DW,Stollings JL,Kumar AB,Hughes CG,Hernandez A,Guillamondegui OD,May AK,Weavind L,Casey JD,Siew ED,Shaw AD,Bernard GR,Rice TW, Balanced Crystalloids versus Saline in Critically Ill Adults. The New England journal of medicine. 2018 Mar 1     [PubMed]

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