PL Detail-Document #290212
−This PL Detail-Document gives subscribers
additional insight related to the Recommendations published in−
PHARMACIST’S LETTER / PRESCRIBER’S LETTER
February 2013
Comparison of IV Fluids
The need for fluid resuscitation, or replacing blood volume with IV fluids to maintain adequate organ perfusion, is not uncommon in the hospital
setting. Options include colloids such as albumin or hydroxyethyl starch (HES) and crystalloids such as normal saline (NS) or lactated Ringer’s (LR)
solution. New studies such as SAFE (Saline versus Albumin Fluid Evaluation) and updated meta-analyses continue to shed light on the best choices.
One often cited advantage of using colloids over crystalloids is that less volume is needed to produce the desired effect. For example, guidelines have
given a 1:4 volume ratio. However, data have not consistently supported this number, with ratios often being closer to 1:1 or 1:2.1-4 Safety and cost
are two major arguments against the use of colloids, along with the lack of evidence for benefit over crystalloids in many patient populations. Studies
comparing IV fluids for fluid resuscitation that are underway include Albumin in Severe Sepsis (ALBIOS), Lactated Ringer Versus Albumin in Early
Sepsis Therapy (RASP), and Efficacy and Safety of Colloids Versus Crystalloids for Fluid Resuscitation in Critically Ill Patients (CRISTAL). The
following chart lists colloid and crystalloid products, alone with advantages, disadvantages, and evidence for use.
Advantages
Disadvantages
Albumin
5%, 25%
Fluid
• Low risk for
adverse reactions5
• May modulate
inflammation5,6
• Colloids may
provide greater
intravascular volume
expansion than equal
volumes of
crystalloids5
• Potential for allergic reactions6
• Potential for transmission of
infection5
• Hyperoncotic albumin may
cause kidney damage5,7
• More expensive than HES or
crystalloids
Dextran 40 (LMD)
10% in D5W or NS
Gentran-40
Dextran 70
6% in D5W or NS
Gentran-70
• Colloids may
provide greater
intravascular volume
expansion than equal
volumes of
crystalloids5
• High risk for adverse reactions5
• Potential for allergic or
anaphylactoid reactions5,7
• Impairs hemostasis (sometimes
used as anticoagulant)4,5,7
• May cause kidney damage7
Comments
• Natural colloid6
• Duration of action 12 to 24 hours5
• 25% albumin is hyperoncotic; 5% albumin is iso-oncotic5,7
• No mortality benefit over NS for fluid resuscitation in hypovolemia
(SAFE)5,6,8
• A slight but nonstatistically significant benefit for albumin shown in
patients with sepsis (SAFE).5 Recommended in severe sepsis and
septic shock for patients who require large amounts of crystalloid.8
• May be beneficial in patients with low albumin5
• Iso-oncotic albumin may improve mortality in cardiac surgery
patients2,5
• Avoid in brain trauma. May increase mortality compared with NS
(SAFE).5
• Artificial colloid
• Duration of action one to two hours (dextran 40)5
• Use for fluid resuscitation has fallen out of favor due to high risk of
adverse reactions4
• LMD = low-molecular-weight dextran
More. . .
Copyright © 2013 by Therapeutic Research Center
3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.PharmacistsLetter.com ~ www.PrescribersLetter.com ~ www.PharmacyTechniciansLetter.com
(PL Detail-Document #290212: Page 2 of 4)
Fluid
Advantages
Disadvantages
Comments
5% Dextrose
(D5W)
• NA
• Pediatric deaths reported from
hyponatremia resulting from
infusion of excess volume of
D5W9
• Crystalloid
• Hypotonic. Isotonic in the bag, but dextrose gets metabolized almost
immediately in the lining of the blood vessels, leaving free water.10
• Hypotonic solutions such as D5W are useful for patients with
dehydration and adequate circulatory volume7,11
Hydroxyethyl starch
(HES)
• May modulate
inflammation5,6
• Colloids may
provide greater
intravascular volume
expansion than equal
volumes of
crystalloids5
• Potential for anaphylactoid
reactions5
• May accumulate in tissue and
cause prolonged itching4-7
• May impair platelet function6
• May cause kidney damage5-7
• May cause increases in serum
amylase7
• More expensive than
crystalloids
• Synthetic colloid
• Duration of action eight to 36 hours5
• 6% HES is hyperoncotic5
• Larger molecular weight than albumin2
• Adverse effects are dose-related12
• Hespan and Hextend are hetastarches. Voluven is a tetrastarch with a
lower molecular weight. This is thought to reduce the risk for adverse
effects; however, it has not been proven.3,4,6,12,13
• May increase mortality, need for dialysis, and bleeding compared
with LR and other fluids in patients with severe sepsis (6S, etc).4,13 Not
recommended for fluid resuscitation in severe sepsis and septic shock.8
• No benefit shown in critically ill patients (e.g., burns, post-op,
trauma) compared with crystalloids1
• Low risk for
adverse reactions5
• Crystalloids freely distribute
across the vascular barrier6
• Risk for respiratory acidosis
due to accumulated CO214
• Risk for hyperkalemia (has
4 mEq/L potassium)5,7
• Impaired metabolism of lactate
to bicarbonate in patients with
severe liver disease10
• Crystalloid
• Duration of action one to four hours5
• Slightly hypotonic5
• Considered equally effective as normal saline11
• May be preferred for hemorrhagic shock because large volumes will
not cause hyperchloremic metabolic acidosis, as with NS7,11
• Because of slight hypotonicity, might increase risk of brain swelling
in brain trauma13,15
6% HES 200/0.5 in NS
Hespan (U.S.),
6% HES 200/0.5 in
lactated electrolyte
solution
Hextend,
6% HES 130/0.4 in NS
Voluven
Lactated Ringer’s
(LR)
More. . .
Copyright © 2013 by Therapeutic Research Center
3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.PharmacistsLetter.com ~ www.PrescribersLetter.com ~ www.PharmacyTechniciansLetter.com
(PL Detail-Document #290212: Page 3 of 4)
Fluid
0.9% NaCl
Normal saline (NS)
Advantages
• Low risk for
adverse reactions5
Disadvantages
• Crystalloids freely distribute
across the vascular barrier6
• Risk of hypernatremia and
hyperchloremic metabolic
acidosis7,14
Comments
• Crystalloid
• Duration of action one to four hours5
• Isotonic
• No mortality benefit of 4% albumin over NS for fluid replacement in
hypovolemia (SAFE)5,6,8
• Considered equally effective as LR. Preferred over LR for patients
with brain trauma.11
• No evidence that hypertonic saline (e.g., 3%) is better than NS for
fluid resuscitation7,11
• Hypotonic solutions such as D5W/ 1/2 NS are useful for patients with
dehydration and adequate circulatory volume7,11
Users of this PL Detail-Document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making
clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national
organizations. Information and internet links in this article were current as of the date of publication.
More. . .
Copyright © 2013 by Therapeutic Research Center
3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.PharmacistsLetter.com ~ www.PrescribersLetter.com ~ www.PharmacyTechniciansLetter.com
(PL Detail-Document #290212: Page 4 of 4)
Project Leader in preparation of this PL DetailDocument:
Stacy A. Hester, R.Ph., BCPS,
Assistant Editor
9.
References
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4.
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6.
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8.
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fluid resuscitation in critically ill patients. Cochrane
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Han J, Martin GS. Rational or rationalized choices in
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Hartog CS, Kohl M, Reinhart K. A systematic review
of third-generation hydroxyethyl starch (HES
130/0.4) in resuscitation: safety not adequately
addressed. Anesth Analg 2011;112:635-45.
Perner A, Haase N, Guttormsen AB, et al.
Hydroxyethyl starch 130/0.42 versus Ringer’s
acetate in severe sepsis.
N Engl J Med
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Kruer RM, Ensor CR. Colloids in the intensive care
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Strunden MS, Heckel K, Goetz AE, Reuter DA.
Perioperative fluid and volume management:
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Plain D5W or hypotonic saline solution post-op could
result in acute hyponatremia and death in healthy
children. ISMP Medication Safety Alert! August 13,
2009.
http://www.ismp.org/newsletters/acutecare/articles/2
0090813.asp. (Accessed January 15, 2013).
Rosenthal K. Tonicity and IV fluids. Resource
Nurse.
http://www.resourcenurse.com/feature_tonicity_fluids
.html. (Accessed January 15, 2013).
Intravenous fluid resuscitation. The Merck Manual.
July 2012.
http://www.merckmanuals.com/profes
sional/critical_care_medicine/shock_and_fluid_resus
citation/intravenous_fluid_resuscitation.html.
(Accessed January 15, 2013).
Traynor K. Trauma experts urge cautious use of i.v.
fluids. Am J Health Syst Pharm 2012;69:1846,1848.
Vincent JL, Gottin L. Type of fluid in severe sepsis
and septic shock. Minerva Anestesiol 2011;77:11906.
The great fluid debate revisited. Medscape Critical
Care (2008). http://www.medscape.org/viewarticle
/572584. (Accessed January 15, 2013).
Ropper AH.
Hyperosmolar therapy for raised
intracranial pressure. N Engl J Med 2012;367:74652.
Cite this document as follows: PL Detail-Document, Comparison of IV Fluids. Pharmacist’s Letter/Prescriber’s
Letter. February 2013.
Evidence and Recommendations You Can Trust…
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Copyright © 2013 by Therapeutic Research Center
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