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Volume Replacement in the Neonatal ICU:

Crystalloids and Colloids


K. G a r y M a g d e s i a n , DVM, Diplomate ACVIM, Diplomate ACVECC, and
John E. M a d i g a n , DVM, MS, Diplomate ACVIM

solutions that contain electrolytes and/or glucose, while col-


The perinatal foal has a higher body water content and turnover
rate than adult horses. Critically ill foals have even more complex loids contain large molecular weight particles, such as proteins,
fluid requirements, dictated by hemodynamic alterations associ- which cannot freely cross capillary membranes. Recommenda-
ated with systemic inflammatory response syndromes such as tions for volume replacement in hypovolemic and dehydrated
sepsis or peripartum asphyxia syndrome. Understanding fluid foals include sequential boluses of 10 to 20 mL/kg of replace-
requirements and available fluid choices is an important part of ment crystalloid over 10 to 30 minutes, x5,16Bolus administra-
managing the ICU patient, to maximize fluid balance and oxygen tion of colloids, at a dose of 3 to 10 mL/kg may be used in
delivery to tissues. This paper reviews some of the unique addition to or instead of crystalloid fluids. After completion of
features of water balance in neonatal foals, fluid requirements for each bolus, the foal's perfusion and hydration parameters
replacement and maintenance needs, as well as available fluid should be reassessed, to determine the need for further volume
choices. Crystalloid and colloid solutions are discussed, empha-
replacement. This fluid volume resuscitation protocol is con-
sizing advantages and disadvantages of each.
servative, in order to avoid rapid alterations in central venous
Key Words: Crystalloids, colloids, fluids, volume support, neo-
natal foal
pressure and subsequent edema formation. Critically ill foals often
Copyright 2003, Elsevier Science (USA). All rights reserved. have altered microvascular permeability and are at risk for edema
formation with only small changes in hydrostatic pressure.

eonatal foals have a larger volume of total body water, Monitoring Replacement CrystaUoid Therapy
N comprising approximately 75 to 83.3 % of body weight, as Assessment of fluid status should include physical examination
compared to 60 to 70% of body weight in the adult horse. 1-5 In
findings, including those that reflect intravascular volume sta-
addition, the extracellular fluid (ECF) compartment is rela-
tus. These perfusion parameters include mentation, heart rate,
tively larger in foals, occupying approximately 39.4 + 2.9 L/kg
extremity temperature, pulse quality, capillary refill time (Fig
of body weight, as opposed to approximately 22 to 29 I_/kg in
1), jugular refill time, mucous membrane color, as well as urine
the adult. 6-~1Neonatal foals are expected to have a higher turn-
production. Hemodynamic monitoring, including measure-
over of body water, as they have a higher metabolic rate than
ment of central venous pressure, arterial blood pressure, colloid
adult horses. Foals have a relatively greater surface area and
osmotic pressure, blood lactate, PrO2 and acid base status
reduced renal concentrating ability in the postpartum period as
compared to adult animals. 12,13 should also be performed. Central venous pressure (CVP) is the
luminal blood pressure of the intrathoracic cranial (or caudal)
Normal urine output in neonatal foals is reported to be ap-
vena cava. It is regulated by central venous blood volume (ve-
proximately 6 mIA~g/h. ~z This high output is related to a large
nous return), venous tone, and cardiac output. CVP can be
mtake of water, in the form of milk. Milk consists of approxi-
measured using a plastic manometer with a three-way stopcock
mately 89 to 90 % water, and healthy foals consume between 15
fastened to extension tubing that is continuous with a central
to 30% of body weight in milk per day. ~,~4 Reflecting this high
venous catheter (Fig 2). Catheters which are 20 to 30 cm in
water intake and urine excretion, normal unne specific gravity
length (such as an Arrow intravenous catheter, Arrow Interna-
in newborn foals, after the first 24 hours postpartum, is usually
tional, Inc, Reading, PA), should be utilized for measurement of
hyposthenuric (<1.008) and is reported to range from 1.001 to
1.027.i2,13 CVP (Fig 3). Placement of the catheter within the cranial vena
cava can be confirmed through thoracic radiography (Fig 4).
Serial monitoring of CVP is useful in evaluating responses to
Fluid Replacement (Volume Resuscitation) fluid boluses. Increase in CVP may be caused by volume over-
load, as might occur with excessive volume replacement or
Fluid deficits can be replaced using crystalloids, colloids, or
right heart failure. There are a number of additional causes of
both (please see discussions below). Briefly, crystalloids are
increased CVP, including increases in pleural or pericardial
pressures or false elevations as might occur with catheter oc-
From the School of Veterinary Medicine, University of California, Davis, clusion or the presence of air in the lines. Normal CVP in
Davis, CA, USA neonatal foals is <10 to 12 cm of water (<9 mmHg). 17 CVP
Address reprint requests to Dr. K. Gary Magdeslan, One Shields Ave, values within the normal range do not rule out hypovolemia,
2108 Tupper Hall, School of Veterinary Medicine, Department of Medi- but overzealous fluid administration will result in increases in
cine and Epidemiology, University of California, Davis, Davis, CA 95616.
Copyright 2003, Elsevier Science (USA). All rights reserved. CVP, and negative results are indicative of hypovolemia. Nor-
1534-7516/03/0201-0001 $35.00/0 mal blood lactate in 24-hour foals is less than 2 to 2.5 mmol/L
doi:l 0.1053/$1534-7516(03)00021-0 (Ref 15, Magdesian, personal observations). Blood lactate ele-

20 Clinical Techniques in Equine Practice, Vol 2, No 1 (March), 2003: pp 20-30


Fig 1. Prolonged capillary refill time may represent hypovolemia or hypotension.

vation occurs most commonly because of absolute or relative Maintenance Fluid Requirements
tissue hypoxia, as with hypovolemia or cytopathic hypoxia,
Exact maintenance fluid requirements in the perinatal foal are
respectively. However, it should be remembered that increases
unknown. There are currently a number of different protocols
in blood lactate concentration may also occur with hypermeta-
bolic states (as with sepsis), decreased clearance (liver failure), used to estimate fluid requirements in this age group of
inhibition of pyruvate dehydrogenase (as with thiamine defi- horses. 16-1s One report recommends a maintenance fluid re-
ciency), and catecholamine surges or inflammatory mediators quirement of 80 to 120 mL/kg/day, which translates to 3 to 5
associated with SIRS. As with CVP, serial measurement of lac- mlJkg/h. Palmer estimates maintenance fluid requirements by
tate, evaluating for trends and alterations, is probably more using the following calculations: 16
important than one particular measurement. Arterial blood 100 mL/kg per day for the first 10 kg of body weight
pressure is discussed m the manuscript on hemodynamic mon- + 50 mL/kg per day for the second 10 kg of body weight
itoring. Fluid balance should also be evaluated through moni- + 20-25 mL/kg per day for the remainder of body weight
toring of water intake and urine output in critically ill foals;
output is measured through means of a urinary catheter (Fig 5), Based on this formula, a 50-kg foal would require approxi-
while input reflects both enteral and parenteral water intakes. mately 100 mldh of fluids for maintenance needs once rehy-
Milk is approximately 89 to 90 % water. Fluid input should be drated. Foals on either protocol should be monitored for ade-
approximately equal to urine output, in addition to estimations quacy of fluid provision.
of insensible losses and water retention for growth. Even more elusive are the fluid requirements of the critically
Hydration parameters, those that reflect interstitial volume ill foal. These likely vary considerably, with a high degree of
status rather than intravascular volume, include skin turgot, interindividual variability. A foal experiencing a systemic in-
tear film production (corneal quality), eye positioning (sunken flammatory response syndrome (SIRS) associated with diarrhea
eyes reflecting dehydration), and mucous membrane texture. will certainly require more daily fluid than one with perinatal
Serial body weight measurements are very useful indicators of asphyxia syndrome and obtundation, recumbency, and com-
total body water changes. promised endothelial integrity.

VOLUME REPLACEMENT IN THE NEONATAL IOU 21


Fig 2. A water manometer and stopcock for measurement of central venous pressure.

Once dehydration and hypovolemia are corrected using re- Complications of Fluid Therapy
placement fluids (as described under 'Fluid Replacement'), the
Complications of paremeral fluid therapy include overhydra-
author recommends initiating fluid plans for critically ill foals
uon and phlebitis. Volume overload and overhydration will be
using one of the methods described here for maintenance. Sub-
sequently, the foal should be monitored serially using clinical reflected by: (1) significantly greater fluid input than output,
examination findings, monitoring tools such as central venous (2) increased CVP, (3) unexpected weight gain, (4) increased
pressure, arterial blood pressure, urine output, and blood lac- skin turgor, (5) peripheral edema as manifested by ventral
tate concentrations, as well as clinical pathologic markers such edema or chemosis, and/or (6) increased respiratory rate or
as total protein, colloid osmotic pressure, and hematocrit or deterioration of blood gases reflecting pulmonary edema. Ex-
packed cell volume. No one of these values will dictate fluid cessive fluid administration should be detected before develop-
needs alone, but rather the combination will monitor trends in ment of edema, and this is where CVP and monitoring of input
fluid balance and thus aid in directing fluid plans. For example, versus output of fluid volume is useful.
a normal hematocrit or total protein should not necessarily Neonatal foals are often supplemented with dextrose in flu-
imply adequate hydration, because these may be independently ids. Because neonatal foals with poor milk intakes are at risk for
low for other reasons, including anemia and protein loss, re- hypoglycemia, fluids should initially provide 4 to 8 mg/kg/min
spectively. Other techniques useful in monitoring fluid balance of dextrose.16 However, hyperglycemia should be avoided dur-
include measurements of body weight, serum albumin concen- ing volume resuscitation because of potential complications,
tration, BUN and creatinine, urine specific gravity, plasma os- such as intracellular acidosis and osmotic diuresis. Intensive
molarity, mixed venous oxygen saturation, thoracic radiogra- insulin therapy with tight regulation of blood glucose has re-
phy, and echocardiography. ceived recent attention in human critical care, and insulin may
In addition to 'replacement' and 'maintenance' fluid require- exert antiinflammatory effects. 19,2 To prevent hyperglycemia,
ments, on-going losses of fluid, as might occur with diarrhea or blood glucose concentrations should be monitored frequently
reflux, should be accounted for in fluid plans. in foals being supplemented with parenteral glucose in fluids.

22 MAGDESIAN AND MADIGAN


Fig 3. A 20-30 cm triple lumen IV catheter is utilized for CVP measurement.

Crystalloids lactate (28 mEq/L) as an alkalinizing agent, which is ultimately


metabolized to glucose (gluconeogenesis) or to carbon dioxide
Crystallolds are fluids containing small molecular weight mol-
and water, leading to a minor contribution of base. 21 Oxidation
ecules, such as electrolytes and glucose, that readily cross cap-
to carbon dioxide and water is as follows:
illary membranes. They fall into one of 2 categories, replace-
ment and maintenance fluids (Table 1). Replacement fluids are NaC3HsO 3 + 302 --+ 2CO 2 + 2H20 + Na + + HCO3-
isotonic to extracellular fluid and distribute accordingly. The
Gluconeogenesis consumes hydrogen ions and is also alkalin-
composition of replacement crystalloids resembles that of
izing. 21 In patients with hepatic dysfunction or failure, the
plasma and the extracellular fluid. In contrast, maintenance
lactate may not be metabolized normally. This may cause a
fluids are hypotonic relative to body fluids, and they distribute
minor increase in plasma lactate concentrations, but will not
among both the intraceflular and extracellular fluid compart-
contribute directly to lactic acidosis because the form of lactate
ments. They contain less sodium and often more potassium
in LRS is the sodium salt. LRS should not be administered
than replacement fluids.
through the same lines as blood or plasma products, as these
contain citrate or other calcium antagonists, and LRS contains
I. Replacement Crystalloids
calcium. Ideally, sodium bicarbonate should not be added di-
Lactated Ringer's Solution. Lactated Ringer's solution (LRS) rectly to LRS, because of potential precipitation with calcium.
is a balanced, isotonic polyionic fluid. It is a good starting or Hartmann's solution is very similar in composition to lactated
first line fluid in foals not suspected of being hyperkalemic, as it Ringer's solution. LRS is also available commercially as a 5%
contains 4 mEq of potassium per liter. The chloride content of dextrose solution.
LRS (109 mEqFL) is relatively higher than that of normal equine Sodium chloride (0.9 % sodium chloride). Physiologic saline
plasma, whereas the sodium concentration is on the lower limit (0.9 % sodium chloride) is an isotonic fluid containing only
of physiologic concentrations (130 mEq/L). This may be a sodium and chloride ions. Its lack of potassium allows it to be
slight disadvantage in treating hyperchloremic patients, as used during hyperkalemic episodes, such as uroperitoneum,
compared to fluids with lower chloride concentrations, such as acute renal failure, and hyperkalemic periodic paralysis crises.
Plasma-Lyte 148 or Normosol R (98 mEqFL). LRS contains However, its sodium to chloride ratio ( l : l ) is relatively greater

VOLUME REPLACEMENT IN THE NEONATAL ICU 23


Fig 4. A thoracic radiograph demonstrating proper placement of an IV catheter within the cranial vena cava.

than that of plasma, which has approximately 130 to 140 Acetate is metabolized primarily in muscle, and this may be an
mEq/L sodium and 90 to 102 mEq/L of chloride. This relative advantage for use in liver failure patients. 21 Another difference
increase in chloride causes saline to effect a mild acidosis, between Plasma-Lyte or Normosol-R and LRS is the relative
because of a relatively greater provision of strong anions as sodium to chloride ratio, with the former fluids having 140
compared to strong cations. Therefore, saline is useful in foals mEq/L sodium and 98 mEq/L chloride. This allows for a larger
with primary metabolic alkalosis, however, this is rarely en- strong ion difference (SID) in Plasma-lyte 148 (SID = 47 mEq/L
countered. Acidosis is common in critically ill foals, making as opposed to approximately - 4 mEq/L in Hartmann's or LRS),
saline a less than optimal fluid choice in these patients. which may be advantageous in patients with metabolic acido-
Plasma-Lyte 148 or Normosol-R. Plasma-Lyte 148 (Baxter sis. = The potassium content of Plasma-Lyte or Normosol is 5
Healthcare Corporation, Deerfield, IL) or Normosol-R (Abbott m E @ . A variety of other Plasma-lyte solutions exist, including
Laboratories, North Chicago, IL) are polyionic crystalloids that Plasma-Lyte A, Plasma-Lyte R, and solutions containing dex-
are similar to LRS with a few notable differences. They contain trose (Baxter Healthcare Corporation), which have slight vari-
magnesium, rather than calcium, and can therefore, be admin- ations on Plasma-Lyte i48.
istered along with plasma or blood products containing citrate. Isotomc bicarbonate. Isotonic bicarbonate solution can be
In addition, they contain acetate (27 mEq/L) and gluconate (23 made by adding 150 mEq of sodium bicarbonate (150 mEq of
mEq/L) as alkalinizers rather than lactate. = sodmm, 150 mEq of bicarbonate) to 1 liter of sterile water. This
Acetate: solution is a good fluid choice for foals with inorganic (hy-
NaC2H302 + 202 --+ CO2 + H20 + Na + + HCO3- ponatremic, hyperchloremic) metabolic acidosis, as well as
those with hyperkalemia, such as those with uroabdomen.
Gluconate:
Foals administered bicarbonate should be monitored for hypo-
2NaC6HnO7 + 1002 --->10CO 2 -~ 10H20 + 2Na + + 2HCO3- kalemia, decreases in ionized calcium, metabolic alkalosis, and

24 MAGDESIAN AND MADIGAN


Fig 5. Human infant feeding tubes can be utilized as urinary catheters in foals.

hypercapnia. Rapid administration of bicarbonate should be 148, and 100 mL of 5% dextrose in water would be adminis-
avoided for these reasons, as well as to avoid the possible de- tered. The proportion of isotomc crystalloid and D5W could be
velopment of paradoxical intracellular acidosis. Potentiation of changed depending on electrolyte and hydration status. Alter-
intracellular acidosis by rapid bicarbonate administration is an natively, commercial maintenance fluids are available.
equivocal phenomenon, which has been documented in Plasma-Lyre 56 or Normosol M. Plasma-Lyre 56 (Baxter
vitro. 23-26 A good rule of thumb is to administer half of the Healthcare Corporation, Deerfield, IL) or Normosol M (Abbott
estimated bicarbonate deficit (body weight in kg base defi- Laboratories, North Chicago, IL) are fluids that are hypoosmo-
cit X 0.4) over 1 to 2 hours @er replacement of fluid deficits, lar relative to the ECF, with an osmolarity of approximately 111
and then to reassess the base deficit. Bicarbonate administration m E @ . As expected, the sodium concentration is lower (40
should be performed with caution in foals with hypoventila- m E @ ) , and potassium, the primary intracellular cation, is
tion, as it may further increase PaCO2. higher (13 m E @ ) . Like their replacement counterparts, these
fluids contain magnesium rather than calcium. They contain
II. Maintenance Crystalloids only acetate (16 mEq/L) as the alkalinizing salt. One difference
Maintenance fluids are indicated in neonatal foals intolerant of from the analogous replacement fluids is that the sodium to
enteral feeding, as they provide an alternate source of free water chloride ratio is 1:1 in these maintenance fluids, which may
for distribution to the intracellular space in addition to the represent a slight disadvantage for acidotic patients with hyper-
ECF. They should be utilized only after the neonate is rehy- chloremia.
drated with replacement fluids. Replacement crystalloids may Sodium chloride (0.45 %) and dextrose in water (2.5%). This
be inappropriate for use as maintenance fluids in foals, because so-called "1/2 strength saline, 1/2 strength dextrose" crystalloid
of the large sodium content, especially in foals intolerant of is also a maintenance fluid. Like the above commercial fluids,
enteral milk intake, aT Maintenance fluids can be developed the sodium: chloride ratio is 1:1, however, the solution lacks
from replacement fluids through the administration of two- potassium or other electrolytes, as well as alkalinizing agents.
thirds the desired fluid rate as 5% dextrose in water (D5W) and The advantage of this solution is that it can be used directly off
one-third as replacement fluid. For example, if the fluid admin- the shelf without having to add dextrose. This solution may be
istration target is 150 mL per hour, then 50 mL of Plasma-Lyte ideal for maintenance of patients with hyperkalemia.

VOLUME REPLACEMENT IN THE NEONATAL ICU 25


Dextrose in water (5 %). Dextrose 5 % in water (D5W) is and directing synthetic colloid therapy from an oncotic pres-
isotonic (250 mOsm/L) as provided commercially. However, sure standpoint. 29,32
because of metabolism of the dextrose, it is a source of free
water. Therefore, it should not be utilized in replacing fluid
deficits or hypovolemia. DSW also provides 170 kcal/L of di- Crystalloids Versus Colloids
gestible energy and is devoid of electrolytes. The ideal fluid for volume resuscitation in the neonatal equine
ICU is unknown. There are a number of conflicting reports in
human critical care medicine causing debate whether crystal-
Colloid Replacement loids or colloids should be used during volume resuscita-
Colloid osmotic pressure (COP) is the osmolarity generated by tion. 37-44 The use of crystalloids versus colloids in pediatric
large molecules that are unable to cross capillary membranes human patients is also controversial. 43.44 Current philosophy
freely. By increasing COP, they serve to promote fluid retention recognizes the advantages of both crystalloids and colloids, and
within the intravascular compartment. In plasma, COP is be- a 'Mending' of the two may be the optimal choice. Insensible
cause of plasma proteins, particularly albumin (60-80 % of and isotonic fluid losses should be replaced with crystalloids.
plasma COP). Albumin is the primary determinant of plasma Isotonic crystalloids distribute among the extracellular fluid
COP because of its relatively high concentration, small size, space, including the intravascular and interstitial spaces, ac-
and highly negative charge (Gibbs-Donnan effect).as The COP cording to their respective volumes. Thus, crystalloids allow for
generated by proteins is above that expected by the concentra- greater interstitial rehydration compared to colloids, which
tion in plasma. This is because of the Gibbs-Donnan effect, may be a disadvantage when edema is present. Expansion of
which relates to the redistribution of ions induced by negatively blood volume with crystalloids results in a decrease in plasma
charged proteins in plasma; these protein 'anions' attract cat- protein concentrations, and thus COP. Colloids allow for main-
ions that would otherwise diffuse freely across the capillary. tenance of plasma oncotic pressure. Colloids are confined to the
Water is osmotically retained with these cations, thereby in- intravascular space, assuming an intact endothelial barrier, and
creasing the amount of intravascular volume. are therefore indicated in hypovolemic shock. 45 Sepsis and
Colloids provide several advantages for volume resuscitation other SIRS conditions may reduce the capillary reflection coef-
of patients experiencing a systemic inflammatory response syn- ficient by compromising capillary integrity, thereby reducing
drome (SIRS). They are effective at replacing intravascular def- the effectiveness of colloids. Marked increases in microvascular
icits rapidly. Smaller volumes and shorter infusion times are permeability, as is associated with some forms of acute respira-
required for volume resuscitation as compared to crystalloids. tory distress syndromes and early burn injuries, are a corltrain-
Other indications for colloids include hypoproteinemia, espe- dication to the administration of colloids, as they will extrava-
cially if coupled to hypovolemia. The author attempts to main- sate and promote edema formation. A deterioration of clinical
tain COP above 14 mmHg when restoring intravascular volume or blood gas parameters post colloid administration may repre-
in horses with acute hypoproteinemia. Judicious use of colloids sent such a state and warrants discontinuation of colloid ther-
is important in foals with elevations in CVP, including those apy.
with cardiac dysfunction. It should be pointed out that colloids The concurrent use of both crystalloid and colloid solutions
do not provide free water, and they should not be utilized as a obviates the need for large volume administration of crystal-
free water source for maintenance. loids, minimizes the risk of interstitial edema, and may restore
blood volume more rapidly than crystalloids alone, while still
Monitoring Oncotic Pressure allowing for interstitial reexpansion. 46-48 A 'blending' of crys-
talloids and colloids should be considered whenever colloids
Monitoring of colloid therapy is essentially the same as for are not contraindicated.
crystalloid therapy, with a few additions. Direct colloid osmotic
pressure and total protein or albumin concentrations should be
Biologic Colloid Solutions
monitored serially during synthetic and plasma colloid admin-
istration, respectively. In addition, clotting times and platelet Plasma. Plasma is an excellent colloid for the critically ill
counts should be monitored in patients receiving synthetic neonate (Fig 6). The administration of large doses of plasma
colloids. Oncotic pressure in normal adult horses ranges be- (20-40 mL/kg) is not cost prohibitive for the neonatal foal,
tween 20 and 30 mmHg. 29-33 The reported colloid osmotic thereby allowing a significant contribution to COP by plasma.
pressure in normal neonatal foals is 18.8 -+ 1.9 mmHg (plasma In addition to albumin, plasma provides immunoglobulins, fi-
COP interval = 15.0-22.6 mmHg, 95% CI). 31 Both direct and bronectin, clotting factors, antithrombin, and other constitu-
indirect methods can be used to measure COP. Direct colloid ents that may benefit patients with SIRS. The COP of plasma
osmometry is performed by means of a colloid osmometer, such products is approximately 20 to 25 mmHg. In addition to pro-
as the Wescor 4420 colloid osmometer (Wescor Inc, Logan viding oncotic pressure, albumin is an important carrier pro-
UT) 34'35 Direct measurements are preferred to indirect calcula- tein for hormones, drugs, and toxins, and therefore has impor-
tions in critically ill patients. 32 Indirect calculations that use tant functions besides generating oncotic pressure. Both stable
total protein or albumin/globulin concentrations, such as the and labile clotting factors are present in fresh (administered to
Landis-Pappenheirner equation, are good estimates of direct the patient within 6 hours of collection) and fresh frozen (fro-
COP in healthy horses and foals, but may not be as accurate in zen within 6 hours of collection without being refrigerated;
clinically ill patients with altered A/G ratios and altered pH or stored for less than 1 year). Stored plasma (frozen for longer
electrolyte compositions. 32,33,36 Indirect measurements do not than 1 year) contains only functional stable factors, including
detect changes in COP produced by synthetic colloids, and factors II, VII, IX, and X. Refrigeration destroys labile coagula-
direct osmometry is therefore the only means of monitoring tion factors (V, VIII, and vWf). Platelet-rich plasma (fresh) is

26 MAGDESIAN AND MADIGAN


Fig 6. Commercial equine plasma is an excellent colloid for use in neonatal foals.

the only source capable of replacing platelets. Because the COP Plasma-Lyte 148 (Baxter Healthcare Corporation) should be
of plasma is equivalent to the oncotic pressure of normal used instead.
horses, and because 60% or more of albumin may redistribute
extravascularly, foals with significant hypoproteinemia may re-
Synthetic Colloids
quire the use of synthetic colloids for additional oncotic sup-
port. Foals receiving plasma transfusions should be monitored Hydroxyethyl starch (Hetastarch). Hetastarch is the most
for signs of hypersensitivity and transfusion reactions, includ- commonly used synthetic colloid in horses (Fig 7).29,3.49 It is a
ing pyrexia, tachycardia, tachypnea, muscle tremors, colic, ur- modified branched-chain glucose polymer originating from
ticaria, and signs of anaphylaxis. Plasma should be adminis- amylopectin. It is available as a 6% aqueous solution in saline
tered through a blood administration set containing filtration (Abbott Laboratories) or lactated electrolyte solution (Hex-
devices. tend@, Abbott Laboratories). The COP of hetastarch is approx-
Whole blood. Whole blood transfusions may be indicated as imately 30 mmHg, making it a more cost-effective colloid than
the colloid of choice in cases of hemorrhagic shock, while plasma. The primary side effect associated with hetastarch ad-
washed dam erythrocytes are ideal for foals with neonatal iso- ministration is an induction of coagulopathies associated with
erythrolysis. Complications associated with blood transfusions reductions in coagulation factor VIII and yon Willebrand's fac-
include reactions due to incompatible red blood cells, as well as tor. Platelet counts and function may also be altered. Hypersen-
those associated with transfer of leukocytes. Citrate toxicity sitivity reactions are also rarely reported. Unlike dextrans,
and hypocalcemia are other potential side effects. Donor ani- hetastarch does not interfere with blood typing or cross match-
mals should be screened for blood-borne diseases. Red blood ing.
cells do not exert oncotic pressure, and therefore packed red There are no studies evaluating hetastarch in foals. Recom-
blood cells do not offer an advantage over whole blood from a mended doses of hetastarch based on studies conducted in
colloid standpoint. Whole blood should not be administered adult horses are up to 8 to 10 ml/kg/day. 29,3,5 Foals in need of
through the same lines as calcium containing fluids, and fluids rapid volume support may be bolused 3-5 ml/kg hetastarch in
without calcium such as Normosol-R (Abbott Laboratories) or addition to crystalloids. In addition to bolus administration,

VOLUME REPLACEMENT IN THE NEONATAL ICU 27


Fig 7. Hetastarch and dextrans are examples of synthetic colloids.

hetastarch can be used as a slow infusion (0.5-1 mL/kg/h, up to drome, thrombocytopenia, or other hypocoagulable states
10 mldkg/day) for colloid support in hypooncotic animals. should not be administered hetastarch.
Until further research is available, larger doses of hetastarch Pentastarch. Pentastarch (DuPont Critical Care, McGaw,
should be used with caution. Foals with von Willebrand's syn- IL) is a narrow-range, medium molecular weight derivative of

28 MAGDESIAN AND MADIGAN


TABLE 1. Electrolyte Composition and Osmolarity of Various Replacement and Maintenance Fluids
Crystalloid Sodium Potassium Chloride Calcium Magnesium Osmolarity Organic

Replacement
LRS 130 4 109 3 0 272-273 28 lactate
Saline (0.9%) 154 0 154 0 0 308 0
Ringers soln 147-148 4 156 4.5 0 310 0
Plasma-Lyte148 140 5 98 0 3 294 27 acetate
23 gluconate
Normosol R 140 5 98 0 3 294 27 acetate
23 gluconate
Maintenance
Plasma-Lyte 56 40 13 40 0 3 111 16
Normosol M 40 13 40 0 3 110 16
0.45% saline/2.5% dextrose 77 0 77 0 0 280 0
5% dextrose 0 0 0 0 0 252-253 0

hetastarch. The COP of pentastarch is 40 mmHg. It is more isoerythrolysis (NI) while awaiting blood transfusion. One case
homogenous than hetastarch in terms of size, excluding very report described the administration of 22 mI_/kg of polymerized
small or large molecules. Advantages over hetastarch include hemoglobin to a foal with NI. 55 In that foal, the Oxyglobin
fewer side effects on the coagulation and reticuloendothelial treatment maintained oxygen delivery for up to 18 hours before
(RE) systems. 51,52 Because of its narrower molecular weight washed red blood cells were administered.
range, pentastarch may be indicated for use in patients with
increased capillary permeability associated with SIRS. Pen-
tastarch shows promise for use in capillary leak syndromes, as it Conclusion
should be retained within the circulation to a greater extent There is little documentation supporting specific parenteral
than hetastarch, and it may aid in plugging leaky capillaries. 53
fluid management practices in neonatal foals. Current recom-
Fractions of colloids with molecular weights between 100 and
mendations are based on a combination of evidence, experi-
1000 kd may represent the ideal size for sealing of widened
ence, and extrapolation from adult horses and neonates of other
endothelial cell gap junctions. Smaller MW molecules ,nay po-
species. Available fluids include crystalloids, both replacement
tentiate third space accumulation of fluid, while larger mole-
and maintenance selections, as well as colloids. Understanding
cules could potentially interfere with sealing.54 Another advan-
the physiologic needs of the critical neonate is the best means of
tage of pentastarch is its potential for larger volume expansion
dictating fluid therapy, and continual reassessment of fluid
as compared to hetastarch.
balance, using clinical and clinicopathologic markers as well as
Dextrans. Dextrans are long glucose polymers produced monitoring tools, is of utmost importance in managing the ICU
from sucrose by the bacterium Leuconostoc mesenteroides (Fig
patient.
7). Dextran 70 is available as a 6% solution (6% Gentran 70,
Baxter Healthcare Corp) with a COP near 60 mmHg. The
higher colloid oncotic pressure of dextran 70 is misleading, as
References
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30 MAGDESIAN AND MADIGAN