NEJM review on fluid resuscitation

The September 26th issue of The New England Journal of Medicine published a review by Myburgh et al on resuscitation fluids.

A few highlights from the review include:

  • Human albumin (4 to 5%) in saline, a colloidal solution is expensive and has limited availibility. Saline versus Albumin Fluid Evaluation (SAFE) study, a blinded, randomized, controlled trial, to examine the safety of albumin in 6997 adults in the ICU. Resuscitation with albumin was associated with a significant increase in the rate of death at 2 years among patients with traumatic brain injury (relative risk, 1.63; 95% CI, 1.17 to 2.26; P=0.003). This outcome has been attributed to increased intracranial pressure, particularly during the first week after injury. Resuscitation with albumin was associated with a decrease in the adjusted risk of death at 28 days in patients with severe sepsis (odds ratio, 0.71; 95% CI, 0.52 to 0.97; P=0.03), suggesting a potential, but unsubstantiated, benefit in patients with severe sepsis.
  • Hydroxyethyl starch (HES): blinded, randomized, controlled trial involving 800 patients with severe sepsis in the ICU, use of 6% HES (130/0.42), as compared with Ringer’s acetate, was associated with a significant increase in the rate of death at 90 days and a significant 35% relative increase in the rate of renal-replacement therapy. In a blinded, randomized, controlled study, called the Crystalloid versus Hydroxyethyl Starch Trial (CHEST), involving 7000 adults in the ICU, the use of 6% HES (130/0.4), as compared with saline, was not associated with a significant difference in the rate of death at 90 days. However, the use of HES was associated with a significant 21% relative increase in the rate of renal-replacement therapy. Both trials showed no significant difference in short-term hemodynamic resuscitation end points, apart from transient increases in central venous pressure and lower vasopressor requirements with HES in CHEST. In CHEST, the use of HES was associated with an increased use of blood products and an increased rate of adverse events, particularly pruritus.
  • Ringer’s solutions: Crystalloids with a chemical composition that approximates extracellular fluid have been termed “balanced” or “physiological” solutions and are derivatives of the original Hartmann’s and Ringer’s solutions. Excessive administration of balanced salt solutions may result in hyperlactatemia, metabolic alkalosis, and hypotonicity (with compounded sodium lactate) and cardiotoxicity (with acetate). Given the concern regarding an excess of sodium and chloride associated with normal saline, balanced salt solutions are increasingly recommended as first-line resuscitation fluids in patients undergoing surgery, patients with trauma, and patients with diabetic ketoacidosis. Resuscitation with balanced salt solutions is a key element in the initial treatment of patients with burns, although there is increasing concern about the adverse effects of fluid overload, and a strategy of “permissive hypovolemia” in such patients has been advocated.

Reference

Resuscitation Fluids; John A. Myburgh, M.B., B.Ch., Ph.D., and Michael G. Mythen, M.D., M.B., B.S.
N Engl J Med 2013; 369:1243–1251September 26, 2013DOI: 10.1056/NEJMra1208627