Indications

Intravenous (IV)

• Hypotension/Shock
  • Anaphylaxis (see Anaphylaxis)
  • Hemorrhagic Shock (see Hemorrhagic Shock)
  • Hypovolemic Shock (see Hypovolemic Shock)
  • Sepsis (see Sepsis)

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Pharmacology

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) (see Normal Saline): 0.9% NaCl
  • Half Normal Saline (see Half Normal Saline): 0.45% NaCl
  • 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 Quarter Normal Saline

• 0.22% w/v NaCl: contains 39 mEq/L of Na and Cl
  • Almost always contains 5% dextrose for osmolality reasons

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Adverse Effects

Cardiovascular Adverse Effects

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

Renal Adverse Effects

• Hyponatremia (see Hyponatremia)

Other Adverse Effects

• Exacerbation of Cirrhotic Ascites (see Ascites)

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References

• Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery. Anesthesiology. 1999 May;90(5):1265-70 [MEDLINE]
• Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012 Oct 17;308(15):1566-72. doi: 10.1001/jama.2012.13356 [MEDLINE]
• Balanced vs unbalanced crystalloid resuscitation in a near-fatal model of hemorrhagic shock and the effects on renal oxygenation, oxidative stress, and inflammation. Resuscitation. 2012 Jun;83(6):767-73. doi: 10.1016/j.resuscitation.2011.11.022. Epub 2011 Dec 4 [MEDLINE]
• The ideal crystalloid – what is ‘balanced’? Curr Opin Crit Care. 2013 Aug;19(4):299-307. doi: 10.1097/MCC.0b013e3283632d46 [MEDLINE]
• Crystalloids for Fluid Resuscitation in Sepsis: Where Is the Balance? Ann Intern Med. 2014 Jul 22. doi: 10.7326/M14-1565 [MEDLINE]